Methods and compositions for diagnosing and treating loss and/or distortion of taste or smell

ABSTRACT

Disclosed herein are methods for diagnosing a subject with loss and/or distortion of taste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia. Also disclosed herein are methods and compositions for treating a subject for loss and/or distortion of taste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia.

This application claims the benefit of U.S. Provisional ApplicationNos.: 61/941,199, filed on Feb. 18, 2014; 62/026,298, filed on Jul. 18,2014; and 62/075,337, filed on Nov. 5, 2014; each of which areincorporated herein by reference in their entireties.

BACKGROUND OF THE DISCLOSURE

Hyposmia is a reduced ability to smell and detect odors. Dysosmia is adistortion of the sense of smell. Anosmia is a complete loss of abilityto smell and detect odors. Phantosmia is a distortion of the sense ofsmell, for example, the perception of a smell in the absence of an odor.Hypogeusia is a reduced ability to taste things. Dysgeusia is adistortion of the sense of taste. Ageusia is a complete loss of abilityto detect or recognize tastens. Phantogeusia is a distortion of thesense of taste for example, the perception of a taste in the absence ofa tasten. There is a need in the art for methods for diagnosing andtreating these conditions.

INCORPORATION BY REFERENCE

All publications, patents, and patent applications herein areincorporated by reference to the same extent as if each individualpublication, patent, or patent application was specifically andindividually indicated to be incorporated by reference. In the event ofa conflict between a term herein and a term in an incorporatedreference, the term herein controls.

SUMMARY OF THE DISCLOSURE

Disclosed herein are methods comprising (a) obtaining one or morebiological samples from a subject; (b) measuring a level of one or moremembers of the hedgehog signaling pathway in the one or more biologicalsamples from the subject; (c) diagnosing the subject with loss ordistortion of taste or smell based upon the level of one or more membersof the hedgehog signaling pathway that is lower than a threshold level;and (d) treating the subject diagnosed with loss or distortion of tasteor smell.

Also disclosed herein are methods comprising (a) obtaining one or morebiological samples from the subject; (b) measuring a level of one ormore members of the hedgehog signaling pathway in the one or morebiological samples from the subject; and (c) diagnosing the subject withloss or distortion of taste or smell based upon the level of one or moremembers of the hedgehog signaling pathway that is lower than a thresholdlevel; wherein the diagnosing is computer implemented.

Further disclosed herein are methods comprising (a) obtaining one ormore biological samples from the subject; (b) measuring a level of oneor more members of the hedgehog signaling pathway in the one or morebiological samples from the subject, wherein the measuring is performedby ELISA; and (c) diagnosing the subject with loss or distortion oftaste or smell based upon the level of one or more members of thehedgehog signaling pathway that is lower than a threshold level.

Disclosed herein are methods of evaluating the improvement in, declinein, no change in, diminution in and/or distortion in taste and/or smell,the method comprising: (a) treating the subject with one or more drugs;(b) obtaining one or more biological samples from the subject; (c)measuring a level of one or more members of the hedgehog signalingpathway in one or more biological samples from the subject; (d)diagnosing the subject with an improvement in, decline in, no change in,diminution in and/or distortion, taste and/or smell, e.g., hyposmia,dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia, phantogeusia,and/or ageusia based upon the level of one or more members of thehedgehog signaling pathway that can be above, lower, and/or the same,than a threshold level; and (e) treating the subject with increased,lower, and/or the same one or more drugs.

Additionally disclosed herein are methods of evaluating the improvementin, decline in, no change in, diminution in and/or distortion in tasteand/or smell, the method comprising: (a) treating the subject with oneor more drugs; (b) obtaining one or more biological samples from thesubject; (c) measuring a level of one or more members of the hedgehogsignaling pathway in the one or more biological samples from thesubject, wherein the measuring is performed by ELISA; and (d) diagnosingthe subject with an improvement in, decline in, no change in, diminutionin and/or distortion, taste and/or smell, e.g., hyposmia, dysosmia,anosmia, phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusiabased upon the level of one or more members of the hedgehog signalingpathway that can be above, lower, and/or the same, than a thresholdlevel.

Further disclosed here are methods of evaluating the improvement in,decline in, no change in, diminution in and/or distortion in tasteand/or smell, the method comprising: (a) treating the subject with oneor more drugs; (b) obtaining one or more biological samples from thesubject; (c) measuring a level of one or more members of the hedgehogsignaling pathway in one or more biological samples from the subject;and (d) diagnosing the subject with an improvement in, decline in, nochange in, diminution in and/or distortion, taste and/or smell, e.g.,hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia based upon the level of one or more membersof the hedgehog signaling pathway that can be above, lower, and/or thesame, than a threshold level; wherein the diagnosing is computerimplemented.

In some embodiments, the subject has taste loss. In some embodiments,the subject has taste loss that is selected from a group consisting of:hypogeusia, dysgeusia, phantosmia, and ageusia. In some embodiments, thesubject has smell loss. In some embodiments, the subject has smell lossthat is selected from a group consisting of: hyposmia, dysosmia,phantogeusia, and anosmia.

In some embodiments, the methods further comprise treating the subject.

In some embodiments, the one or more biological samples comprises awhole blood sample, a serum sample, a plasma sample, a urine sample, asaliva sample, a mucus sample, a perspiration sample, or any combinationthereof. In some embodiments, the one or more biological samplescomprise a saliva sample. In some embodiments, the one or morebiological samples comprise a mucus sample.

In some embodiments, the one or more members of the hedgehog signalingpathway is selected from a group consisting of: Sonic Hedgehog (SHH),Desert Hedgehog (DHH), Indian hedgehog (IHH), and any combinationthereof. In some embodiments, the threshold level is an average levelfor one or more members of the hedgehog signaling pathway as measured ina control population comprising subjects with normal olfactory and/orgustatory function. In some embodiments, the level of one or moremembers of the hedgehog signaling pathway is at least one order ofmagnitude lower than said threshold level. In some embodiments, themeasuring comprises using one or more antibodies that bind one or moremembers of the hedgehog signaling pathway.

In some embodiments, the methods further comprise evaluating thesubject's gustatory and/or olfactory function by determining a detectionthreshold (DT) score, a recognition threshold (RT) score, a magnitudeestimation (ME) score, or any combination thereof with a forced-choice,three-stimuli, stepwise-staircase technique using one or more olfactiontesting compounds. In some embodiments, the method further comprisestreating the subject, wherein the treating comprises administering atleast one therapeutic agent. In some embodiments, the at least onetherapeutic agent comprises theophylline, riociguat, forskolin, or anycombination thereof. In some embodiments, the at least one therapeuticagent comprises theophylline. In some embodiments, the at least onetherapeutic agent is in a composition or dosage unit. In someembodiments, the composition or dosage unit is steroid-free. In someembodiments, the one or more therapeutic agents comprise an effectiveamount of one or more phosphodiesterase inhibitors. In some embodiments,the one or more phosphodiesterase inhibitors comprise a non-selectivephosphodiesterase inhibitor, a phosphodiesterase-1 selective inhibitor,a phosphodiesterase-2 selective inhibitor, a phosphodiesterase-3selective inhibitor, a phosphodiesterase-4 selective inhibitor, aphosphodiesterase-5 selective inhibitor, a phosphodiesterase-10selective inhibitor, or any combination thereof.

In some embodiments, the administering is intranasal administration. Insome embodiments, the treatment results in increasing the level of oneor more members of the hedgehog signaling pathway.

Further disclosed herein is a method of diagnosing loss or distortion oftaste or smell in a subject, the method comprising: (a) obtaining one ormore biological samples from the subject; (b) measuring a level of oneor more members of the hedgehog signaling pathway in one or morebiological samples from the subject; and (c) diagnosing the subject withloss or distortion of taste or smell based on one or more of: (i) alevel of Sonic Hedgehog (SHH) that ranges from about greater than 0pg/mL to about 8,500 pg/mL; (ii) a level of Indian hedgehog (IHH) thatranges from about greater than 0 pg/mL about to 1.0 pg/mL; or (iii) alevel of Desert Hedgehog (DHH) that ranges from about greater than 0pg/mL to about 5.0 pg/mL.

Also disclosed herein are methods of treating loss or distortion oftaste or smell in a subject, the method comprising increasing ormaintaining a level of one or more members of the hedgehog signalingpathway.

In some embodiments, the one or more members of the hedgehog signalingpathway are selected from a group consisting of: Sonic Hedgehog (SHH),Desert Hedgehog (DHH), Indian hedgehog (IHH), and any combinationthereof. In some embodiments, the increasing or maintaining the level ofone or more members of the hedgehog signaling pathway comprises givingthe subject one or more cyclic adenosine monophosphate activators and/orcyclic guanosine monophosphate activators. In some embodiments, the oneor more cyclic adenosine monophosphate activators and/or cyclicguanosine monophosphate activators are given in combination with one ormore additional therapeutic agents. In some embodiments, the one or morecyclic guanosine monophosphate activators is riociguat. In someembodiments, the riociguat is present in an amount ranging from greaterthan 0.0 μg to less than or equal to about 250 μg. In some embodiments,the one or more additional therapeutic agents comprise an effectiveamount of one or more phosphodiesterase inhibitors. In some embodiments,the one or more phosphodiesterase inhibitors comprise a non-selectivephosphodiesterase inhibitor, a phosphodiesterase-1 selective inhibitor,a phosphodiesterase-2 selective inhibitor, a phosphodiesterase-3selective inhibitor, a phosphodiesterase-4 selective inhibitor, aphosphodiesterase-5 selective inhibitor, a phosphodiesterase-10selective inhibitor, or combinations thereof. In some embodiments, theone or more additional therapeutic agents comprises theophylline in anamount ranging from greater than 0 mg to less than or equal to about 45mg.

In some embodiments, the method comprises administering to the subjectone or more additional therapeutic agents, wherein the one or moreadditional therapeutic agents comprises forskolin in an amount rangingfrom greater than 0 mg to less than or equal to about 500 mg.

Also disclosed herein are pharmaceutical dosage units comprising one ormore cyclic guanosine monophosphate activators and one or more cyclicadenosine monophosphate activators. In some embodiments, thepharmaceutical dosage comprises one or more cyclic guanosinemonophosphate activators selected from a group consisting of3-(5′-hydroxymethyl-2′-furyl)-1-benzylindazole (YC-1), YC-1 derivatives,anthranilic acids derivatives, ataciguat (HMR1766), benzydamine analogs,CFM1517, A-350619, nitrovasodilators, molsidomine, nitroxyl (HNO), BAY41-2272, BAY 41-8543, BAY 58-2667, cinaciguat (BAY 58-2667), riociguat(BAY 63-2521), and combinations thereof. In some embodiments, the one ormore cyclic guanosine monophosphate activators is riociguat. In someembodiments, the one or more cyclic adenosine monophosphate activatorsis selected from a group consisting of:3-(5′-hydroxymethyl-2′-furyl)-1-benzylindazole (YC-1), glucagon, PDEinhibitors, prostaglandin E1 (PGE1), forskolin, β-adrenergic agonists,and combinations thereof. In some embodiments, the one or more cyclicadenosine monophosphate activators comprises forskolin. In someembodiments, the cyclic adenosine monophosphate activators istheophylline. In some embodiments, the dosage unit is steroid-free.

In some embodiments, the effective amount of the one or morephosphodiesterase inhibitors is, individually, a positive amountselected from the group consisting of less than about 100 mg, less thanabout 75 mg, less than about 50 mg, less than about 25 mg, less thanabout 20 mg, less than about 10 mg, less than about 5 mg, less thanabout 1 mg, less than about 0.5 mg, or less than about 0.1 mg.

In some embodiments, the method, composition, or unit dose, is anintranasal composition, and/or the administration or treating is anintranasal administration or treatment. In some embodiments, the methodof treating appetite loss comprises administering to a subject in needthereof, a dose of a PDE inhibitor. In some embodiments, the dose of aPDE inhibitor is effective to ameliorate appetite loss associated withtaste and/or smell loss. In some embodiments, the effective amount ofthe one or more PDE inhibitors is, individually, a positive amountselected from the group consisting of less than about 100 mg, less thanabout 75 mg, less than about 50 mg, less than about 25 mg, less thanabout 20 mg, less than about 10 mg, less than about 5 mg, less thanabout 1 mg, less than about 0.5 mg, or less than about 0.1 mg.

In some embodiments, the subject in need is a cancer patient. In someembodiments, the cancer patient is undergoing chemotherapy. In someembodiments, the cancer patient is undergoing radiation therapy. In someembodiments, the PDE inhibitor comprises a selective PDE inhibitor. Insome embodiments, the PDE inhibitor comprises a non-selective PDEinhibitor. In some embodiments, the non-selective PDE inhibitorcomprises theophylline. In some embodiments, the method does notcomprise administering a steroid. In some embodiments, the PDE inhibitoris administered intranasally.

In some embodiments, the method further comprises administering anantiemetic. In some embodiments, the antiemetic is selected from a groupconsisting of 5-HT3 receptor antagonists, Dopamine antagonists, NK1receptor antagonist, Antihistamines (H1 histamine receptor antagonists),Cannabinoids, Benzodiazepines, Anticholinergics, and steroids. In someembodiments, the antiemetic is selected from a group consisting ofDolasetron (Anzemet), Granisetron (Kytril, Sancuso), Ondansetron(Zofran), Tropisetron (Setrovel, Navoban), Palonosetron (Aloxi),Mirtazapine (Remeron), Domperidone (Motilium), Olanzapine (Zyprexa),Droperidol, haloperidol, chlorpromazine, prochlorperazine, Alizapride,Prochlorperazine (Compazine, Stemzine, Buccastem, Stemetil, Phenotil),Metoclopramide (Reglan), Aprepitant (Emend), Casopitant, Cyclizine,Diphenhydramine (Benadryl), Dimenhydrinate (Gravol, Dramamine),Doxylamine, Meclizine (Bonine, Antivert), Promethazine (Pentazine,Phenergan, Promacot), Hydroxyzine (Vistaril), Cannabis, Dronabinol(Marinol), synthetic cannabinoids such as Nabilone (Cesamet) or the JWHseries, Sativex, Midazolam, Lorazepam (Ativan), Hyoscine (also known asscopolamine), Dexamethasone (Decadron), Trimethobenzamide, Ginger,Emetrol, Propofol, Muscimol, Peppermint, and Ajwain. In someembodiments, the antiemetic is, individually, a positive amount from 0.1mg to 500 mg. In some embodiments, the antiemetic is, individually, apositive amount selected from the group consisting of 0.3-0.6 mg, 0.5mg, 25-50 mg, 25-100 mg, 25 mg, 12.5-25 mg, 0.5-2 mg, 0.25-2 mg, 0.5-2.5mg, 2.5-5 mg, 1-3 mg, 1-5 mg, 5-15 mg, 4 mg, 8 mg, 8-20 mg, 250-500 mg,12.5-25 mg, 25-50 mg, 50-100 mg, 5-10 mg, 10-30 mg, 10 mg, 100 mg, 0.1-1mg, 4-8 mg, and 1-4 mg.

BRIEF DESCRIPTION OF THE DRAWINGS

The novel features of the invention are set forth with particularity inthe appended claims. A better understanding of the features andadvantages of the present invention will be obtained by reference to thefollowing detailed description that sets forth illustrative embodiments,in which the principles of the invention are utilized, and theaccompanying drawings of which:

FIG. 1: Saliva and nasal mucus IL-1α by age (in pg/ml) in patients withhyposmia. Levels of IL-1α are shown on the ordinate, age in 10 yr groupson the abscissa. Mean levels are shown by the height of the blue barwith SEM indicated. Values were not obtained for blood plasma or urine.

FIG. 2: Nasal mucus IL-1β by age. The figure is structured as in FIG. 1.Values were not obtained in saliva, blood plasma or urine.

FIG. 3: Blood plasma, urine, saliva and nasal mucus IL-1ra by age. Thefigures are structured as in FIG. 1.

FIG. 4: Blood plasma, urine, saliva and nasal mucus IL-1 RII by age. Thefigures are structured as in FIG. 1.

FIG. 5: Blood plasma, urine, saliva and nasal mucus IL-2R by age. Thefigures are structured as in FIG. 1.

FIG. 6: Blood plasma, urine, saliva and nasal mucus IL-6 by age. Thefigures are structured as in FIG. 1.

FIG. 7: Blood plasma, saliva and nasal mucus IL-10 by age. The figuresare structured as in FIG. 1. Values were not obtained in urine.

FIG. 8: Blood plasma, saliva and nasal mucus IL-18 by age. The figuresare structured as in FIG. 1. Values were not obtained in urine.

FIG. 9: Plasma, urine, saliva and nasal mucus in TNF-α by age. Thefigures are structured as in FIG. 1.

FIG. 10: Blood plasma, saliva and nasal mucus IFN-β by age. The figuresare structured as in FIG. 1. Values were not obtained in urine.

FIG. 11: Nasal mucus in IFN-γ by age. The figures are structured as inFIG. 1. Values were not obtained in blood plasma, urine or saliva.

FIG. 12: Illustrates an exemplary course of events related to a methodof diagnosing a taste or smell disorders.

FIG. 13: Depicts a computer system useful for displaying, storing,retrieving, or calculating diagnostic results from a level of one ormore biomarkers associated with taste or smell disorders; displaying,storing, retrieving, or calculating raw data from biomarker analysis; ordisplaying, storing, retrieving, or calculating any sample or subjectinformation useful in the diagnostic methods disclosed herein.

FIG. 14: Parotid saliva cAMP with respect to age. Hatched bars reflectcAMP with lines indicating ±1 SEM. Dotted bars reflect cAMP/protein withlines indicating ±1 SEM. There is a complex shaped function with agewith a peak at age 41-50 yr., decreasing thereafter with a finalincrease at age >70 y.

FIG. 15: Parotid saliva cGMP with respect to age. Hatched bars reflectcGMP with lines indicating ±1 SEM. Dotted bars reflect cGMP/protein withlines indicating ±1 SEM. cGMP increases with age with a peak at age41-50 yr., decreasing thereafter with a final increase at age >70 y.

DETAILED DESCRIPTION OF THE DISCLOSURE

The following description and examples illustrate embodiments of theinvention in detail. It is to be understood that this invention is notlimited to the particular embodiments described herein and as such canvary. Those of skill in the art will recognize that there are numerousvariations and modifications of this invention, which are encompassedwithin its scope.

Definitions

The term “about” as used herein and its grammatical equivalents, inrelation to a reference numerical value can include a range of valuesplus or minus 10% from that value. For example the amount “about 10” caninclude amounts from 9 to 11. In other embodiments, the term “about” inrelation to a reference numerical value can include a range of valuesplus or minus 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, or 1% from thatvalue.

The term “diagnosis” as used herein and its grammatical equivalents canmean the testing of subjects to determine if they have a particulartrait for use in a clinical decision. Diagnosis can include testing ofsubjects at risk of developing a particular disease resulting frominfection by an infectious organism or a non-infectious disease, such ascancer or a metabolic disease. Diagnosis can also include testing ofsubjects who have developed particular symptoms to determine the causeof the symptoms. Diagnosis can also include prognosis, monitoringprogress of a disease, and monitoring the efficacy of therapeuticregimens. The result of a diagnosis can be used to classify patientsinto groups for performance of clinical trials for administration ofcertain therapies.

The term “drug” as used herein and its grammatical equivalents can meanany compounds of any degree of complexity that perturbs a biologicalstate, whether by known or unknown mechanisms and whether or not theyare used therapeutically. Drugs thus can include: typical smallmolecules of research or therapeutic interest; naturally-occurringfactors, such as endocrine, paracrine, or autocrine factors or factorsinteracting with cell receptors of all types; intracellular factors,such as elements of intracellular signaling pathways; factors isolatedfrom other natural sources; pesticides; herbicides; and insecticides.The term “drug” as used herein and its grammatical equivalents can alsorefer to its free-base, acid, salts, esters, and mixtures thereof. If adrug is a salt, it can refer to a pharmaceutically acceptable salt,including but not limited to the salts found in the “Handbook ofPharmaceutical Salts: Properties, Selection, and Use,” R. Heinrich Stahland Camile G. Wermuth, eds., Wiley-VCH, 2^(nd) Edition (2011),incorporated herein by reference in its entirety. For example, the drugscan be formulated into, but not limited to, hydrochloride salts,hydrobromide salts, hydroiodide salts, fumaric acid salts, maleic acidsalts, amino acid salts, mineral acid salts, addition salts, nitratesalts, phosphate salts, succinate salts, maleate salts, fumarate salts,citrate salts, tartrate salts, gluconate salts, lactate salts,lactobionate salts, lauryl sulfate salts, glutamate salts,acetamidobenzoate salts, potassium salts, sodium salts, calcium salts,tromethamine salts, 2-aminoethanol salts, lysine salts, and/or argininesalts.

The term “treating” as used herein and its grammatical equivalents caninclude achieving a therapeutic benefit and/or a prophylactic benefit.Therapeutic benefit can be eradication or amelioration of the underlyingdisorder being treated. Also, a therapeutic benefit can be achieved withthe eradication or amelioration of one or more of the physiologicalsymptoms associated with the underlying disorder such that animprovement can be observed in the patient, notwithstanding that thepatient may still be afflicted with the underlying disorder. Forprophylactic benefit, the compositions can be administered to a patientat risk of developing a particular disease, or to a patient reportingone or more of the physiological symptoms of a disease, even though adiagnosis of this disease may not have been made.

“Therapeutically effective amount” as used herein and its grammaticalequivalents can refer to the amount of an active ingredient, with orwithout additional active ingredients, which can be effective to achieveits intended purpose. While individual patient needs may vary,determination of optimal ranges for effective amounts of the compoundsand compositions is within the skill of an ordinary practitioner of theart. Generally, the dosage required to provide an effective amount ofthe composition, and which can be adjusted by one of ordinary skill inthe art, can vary depending on the age, health, physical condition, sex,weight, extent of the dysfunction of the recipient, frequency oftreatment and the nature, and scope of the dysfunction.

The terms “patient” or “subject” as used herein and its grammaticalequivalents can include mammals, such as humans, including those in needof treatment thereof. Depending on the context, the terms “patient” and“subject” can sometimes be used interchangeably.

The term “average” as used herein and its grammatical equivalents canrefer to the mathematical mean. Typically the mean can be calculated bythe adding together a defined group of numbers and dividing the sum bythe number of members in the group. For example, the mean of the groupof numbers 1, 2, 3, 4, and 5 is 3 ((1+2+3+4+5)/(5) is 3).

The term “activator” as used herein and its grammatical equivalents canbe used to describe a substance that leads to an increase in anothere.g., measured substance. For example, a cAMP activator can lead to anincrease the level of cAMP; a cGMP activator can lead to an increase thelevel of cGMP; or a SHH activator can lead to an increase the level ofSHH.

The term “level” as used herein and its grammatical equivalents, whenused in context with measuring, can refer to e.g., the level of anucleic acid, a protein, cells, etc. For example, SHH levels can meanSHH protein or SHH nucleic acid levels. In some cases, e.g., when theterm “level” refers to proteins, the term “level” can also refer toenzymatic activity. In some cases, e.g., when the term “level” refers toconcentration, the term “level” can also refer to the concentration ofsubstance (e.g., expressed as per protein) or the amount of substance(e.g., expressed as per protein).

The terms “dosage” and “dosage amounts” as used herein and itsgrammatical equivalents can mean that the referenced drug(s) can beformulated into any type of dosage forms suitable for oraladministration, transmucosal administration, buccal administration,inhalation administration, intranasal administration, parentaladministration, intravenous administration, subcutaneous administration,intramuscular administration, sublingual administration, transdermaladministration, and rectal administration.

The term “specific PDE inhibitor” or “selective PDE inhibitor” as usedherein and their grammatical equivalents can be used to describeselectivity over one specific subtype of PDE receptor, e.g., has apreference to inhibit one specific PDE receptor subtype, but can alsoexhibit a certain degree of promiscuity. The degree of promiscuity canvary, but is less than 50%, for example, 49%, 45%, 40%, 35%, 30%, 25%,20%, 15%, 10%, or 5% or less.

The term “communication medium” as used herein and its grammaticalequivalents can refer to any means of communicating information.Exemplary types of communication medium can include, but are not limitedto written, printed, and electronic types of media. Other types ofcommunication medium will be apparent to those skilled in the relevantarts without departing from the spirit and scope of the presentdisclosure.

The term “combination thereof” as used herein and its grammaticalequivalents can refer to one or more members of the recited group. Forexample, if the group comprises A, B, or any combination thereof, eachof A individually, B individually, and the group A and B arecontemplated.

The term “olfactometry” as used herein and its grammatical equivalentscan refer to the testing and measurement of the sensitivity of the senseof smell. For example, olfactometry can be measured by determination ofdetection (DT) and recognition (RT) thresholds, magnitude estimation(ME) and hedonic evaluation (H) for four odors (pyridine, nitrobenzene,thiophene and amyl acetate). Additionally, abnormalities of smellfunction can consist of increased DT and/or RT above normal (decreasedsensitivity) and/or decreased ME (decreased sensitivity) for one or moreof the odors presented or decreased unpleasantness for odors of pyridineand thiophene or increased unpleasantness for odors of nitrobenzene oramyl acetate.

The term “subjective improvement” as used herein and its grammaticalequivalents can refer to measurements of improvement in perception forall external odors based upon a scale of 1-100 with 100 indicatingcomplete recovery of normal smell function with responses from 1-100scaled appropriately. “Subjective improvement” and its grammaticalequivalents can refer to the improvement in flavor perception as can bemeasured by responses of a 1-100 scale with 100 indicating that allflavors of food were considered normal and responses <100 scaledconsistently less. Subjective improvement in taste function can also bemeasured with changes in taste for salt, sweet, sour and bitter tastantsmeasured on the same 1-100 scale with 100 indicating return to normalfor each of the four tastants considered and responses <100 scaledconsistently less.

Method Embodiments

The loss or distortion of taste or smell is a problem affectingpotentially millions of people. However, there are no good biochemicalmarkers that can be used to effectively diagnose this loss or distortionof taste or smell. There are also no good treatment options currently onthe market to treat loss or distortion of taste or smell.

Disclosed herein are methods for diagnosing and/or treating a subjectwith loss and/or distortion of taste or smell, e.g., hyposmia, dysosmia,anosmia, phantosmia, hypogeusia, dysgeusia, phantogeusia, and/orageusia. The methods can comprise (a) obtaining one or more biologicalsamples from the subject; (b) measuring a level of one or more membersof the hedgehog signaling pathway in one or more biological samples fromthe subject; and (c) diagnosing the subject with loss and/or distortionof taste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia,hypogeusia, dysgeusia, phantogeusia, and/or ageusia based upon a levelof one or more members of the hedgehog signaling pathway that can belower than a threshold level. The methods of this invention can furthercomprise at least one of: (a) treating the subject diagnosed with lossand/or distortion of taste or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia; (b)transferring the diagnosed result via a communication medium; and (c)computer implementing the diagnosis.

Also disclosed herein are methods of evaluating the improvement in,decline in, and/or no change in, taste and/or smell, e.g., hyposmia,dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia, phantogeusia,and/or ageusia in a subject. The methods can comprise (a) treating thesubject with one or more drugs; (b) obtaining one or more biologicalsamples from the subject; (c) measuring a level of one or more membersof the hedgehog signaling pathway in one or more biological samples fromthe subject; and (d) diagnosing the subject with an improvement in,decline in, no change in, diminution in and/or distortion in tasteand/or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia,dysgeusia, phantogeusia, and/or ageusia based upon the level of one ormore members of the hedgehog signaling pathway that can be above, lower,and/or the same, than a threshold level.

The methods described herein can comprise analyzing one or morebiological samples from a subject to determine a level of one or morebiological substances. The one or more biological samples can compriseone or more bodily fluids. The one or more bodily fluids can comprise,for example, a whole blood sample, a serum sample, a plasma sample, aurine sample, a saliva sample, a mucus sample, a perspiration sample, orany combination thereof. In some instances, the one or more biologicalsamples can comprise the mucus sample. More specifically, the mucussample can comprise a nasal mucus sample. Use of nasal specimens (e.g.,the nasal mucus sample) can provide a minimally invasive manner ofobtaining biological samples for analysis. In other cases, the one ormore biological samples can comprise the saliva sample. Use of salivasample can provide an alternative minimally invasive manner of obtainingbiological samples for analysis. Another minimally invasive way toextract a bodily fluid from a patient is by collecting a perspirationsample. Methods to collect perspiration samples are within the abilitiesof a person of skill in the art. Some patients may prefer to have ablood test. In these instances, the bodily fluids can be whole blood,plasma, or serum samples, and can be used separately or in combinationwith each other. The results of this analysis can be suitable for use indiagnosis, prognosis, and determination of suitability of therapeuticinterventions.

The term “one or more members of the hedgehog signaling pathway” as usedherein and its grammatical equivalents can include known or unknownmembers of the hedgehog signaling pathway. For example, known members ofthe hedgehog signaling pathway can include the currently known membersof the hedgehog signaling pathway, Sonic Hedgehog (SHH), Desert Hedgehog(DHH), and Indian hedgehog (IHH). Unknown members of the hedgehogsignaling pathway can be found by comparing the homology of nucleic acidand proteins sequences. Although, the invention is directed towards theall of the members of the hedgehog signaling pathway, specific hedgehogmembers can be of significant influence. Therefore, it is contemplatedthat the invention can focus on SHH, DHH, IHH, or any combinationthereof. For example, the embodiments disclosed herein can be focused onSHH.

The term “biological substance” as used herein and its grammaticalequivalents can include cells and/or their extra-cellular and/orintra-cellular constituent(s). For example, biological substances caninclude pathogens, metabolites, DNA, RNA, lipids, proteins,carbohydrates, receptors, enzymes, hormones, growth factors, growthinhibitory factors, cells, organs, tissues, portions of cells, tissues,and/or organs, subcellular organelles, chemically reactive moleculeslike H⁺, superoxides, ATP, citric acid, protein albumin, as well ascombinations or aggregate representations of these types of biologicalvariables. In addition, biological substances can include therapeuticagents such as, but not limited to, methotrexate, steroids,non-steroidal anti-inflammatory drugs, soluble TNF-alpha receptor,TNF-alpha antibody, and interleukin-1 receptor antagonists.

Biological substances can comprise one or more members of the hedgehogsignaling pathway selected from a group consisting of SHH, DHH, and IHH.The level of one or more members of the hedgehog signaling pathway canindicate whether a subject has loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia. As disclosed herein, the “level of one ormore members of the hedgehog signaling pathway” can refer to itsbiological levels, e.g., nucleic acid and/or protein.

Biological substances can comprise cytokines, such a pro-inflammatorycytokines or anti-inflammatory cytokines. Pro-inflammatory cytokines caninclude IL-1α, IL-1β, IL-6, IL-18, TNF-α, or any combination thereof.Anti-inflammatory cytokines can include IL-1ra, IL-10, IFN-γ, IFN-β, orany combination thereof. The balance of pro- and anti-inflammatorycytokines can also indicate whether a subject has loss and/or distortionof taste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia,hypogeusia, dysgeusia, phantogeusia, and/or ageusia.

Biological substances can comprise cytokine receptors such as type Icytokine receptors, type II cytokine receptors, members of theimmunoglobulin superfamily, members of the tumor necrosis factorreceptor family, chemokine receptors, and or TGF beta receptors. Acytokine receptor can include IL-1 RII and/or IL-2R.

Biological substances can comprise eosinophils. Biological substancescan also comprise IgE protein. Biological substances can comprise cyclicnucleotides (e.g., cAMP and cGMP). Biological substances can alsocomprise nitric oxide (NO).

The levels of the one or more biological substances can be compared,individually, to a threshold level. Threshold levels, as describedherein, can be an average level for a particular biological substance asmeasured in a control population comprising subjects with normal tasteand/or smell function. For example, if the level of the biologicalsubstance is above or below the threshold level for the biologicalsubstance, the subject can be diagnosed with and/or treated for lossand/or distortion of taste or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia. Incertain cases, the level of one or more members of the hedgehogsignaling pathway is at least one order of magnitude lower than saidthreshold level. For example, 2, 3, 4, 5, 10, 15, 16, 17, 18, 19, 20,21, 22, 23, 24, 25, 26, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37,38, 39, 40, 41, 42, 43, 44, 45, 50, 60, 70 80, 90, 100, 150, 200, 250,300, 400, 500, 600, 700, 800, 900, or 1000 or more orders of magnitudelower than said threshold level.

Sample Collection

The methods as described herein can use one or more biological samples.The biological sample can be collected from various sources by variousmethods, including but not limited to those described throughout. Theseone or more biological samples can be collected from a subject foranalysis. The one or more biological samples can comprise one or morebodily fluids. For example, the one or more bodily fluids can comprise awhole blood sample, a serum sample, a plasma sample, a urine sample, asaliva sample, a mucus sample, a perspiration sample, or any combinationthereof. One of the most easily accessible bodily fluids is mucus, whichcan be a nasal mucus sample; this invention contemplates using nasalmucus samples. Another easily accessible bodily fluid can be saliva andis specifically contemplated in the embodiments as disclosed herein.Additionally, because blood sample are sometimes easily accessible aswell, the one or more bodily fluids can comprise a plasma sample, aserum sample, a whole blood sample, or any combination thereof. Anothereasily accessible bodily fluid that can be used in the invention is aperspiration sample.

If the one or more biological specimens is, for example, from the nasalarea (e.g., a nasal mucus sample), the sample of nasal secretions can becollected directly from the nose into a collection tube or device.Alternative collection methods are also contemplated. For example, asample of nasal secretion can be collected on a sample collection deviceby passing it into the nostril of a patient. The device can be insertedsequentially into each nostril of the patient and advanced parallel tothe hard palate with slow rotation. The device can then be typicallytransferred to a transport tube, such as a glass or plastic test tube.The transport tube can include a suitable volume of a sterile mediumsuch as ethanol or the like.

Other bodily fluids, such as a saliva sample can be obtained, forexample, by draining, spitting, suction, and/or swabbing, to collectsaliva, for example, mixed saliva. In order to better promotecollection, gustatory or masticatory stimulation can be used to increasethe flow of saliva. Another collection method can be by the use of amodified Lashley cup placed over the Stensen's duct, or with lingualstimulation with lemon juice to obtain parotid saliva, for example, puresaliva.

As previously described above, a blood sample can be collected, forexample, by venipuncture, or finger sticking. Whole blood samples can becollected, for example, in a tube (e.g., a vacuum tube, a capillarytube), a syringe, or a bag. Plasma and serum samples can be derived fromblood samples, e.g., by centrifugation.

A urine sample can be collected, e.g., in a cup, or in a 24-hourcollection.

A perspiration sample can be collected, e.g., in a tube, and can befurther purified for analysis. Collection can occur by any known method.In particular, a sweat sample can be collected using a special sweatstimulation procedure. For example, (a) a sweat-stimulating liquid canbe applied to the skin creating a stimulated area; (b) an electrode canbe placed on the stimulated area; (c) the stimulated area can be exposedto a weak electrical; and (d) sweat can be collected from the stimulatedarea into a plastic coil of tubing or onto a piece of gauze or filterpaper.

A nasal sample collection device can be a swab, a wooden spatula,bibulous materials such as a cotton ball, filter, or gauze pad, anabsorbent-tipped applicator, capillary tube, or a pipette. A swab can beused as a sample collection device, and the sample processing elementcan comprise a swab holder or a swab processing insert. The swab holderor swab processing insert can be tapered or angled to allow a singlesample processing element to accommodate all types of swabs by allowingswabs with different amounts of fiber, or that are wound to differentlevels of tightness, to be held securely within the holder or insert. Incertain cases, the swab holder or swab processing insert can securelyhold the swab to provide stability. Nasal samples can also be collectedfrom spontaneous discharge from the nasal cavity.

Samples can be collected from individuals repeatedly (e.g., once a day,once a week, once a month, biannually or annually) over a period of time(e.g., a day, a week, a month, more than one month, biannually,annually, several years, etc.) Obtaining numerous samples from anindividual over a period of time can be used to verify results fromearlier detections and/or to identify an alteration as a result of, forexample, drug treatment. Samples can be obtained from humans ornon-humans.

Analysis

Once the samples are collected, they can be used to determine levels ofone or more relevant biological substances.

One or more biological samples can be collected and analyzed using oneor more analytical techniques including enzymatic technique, ELISA,fluorometric technique, mass spectrography, visible spectrophotometrictechniques, HPLC, GLC, PCR, protein and nucleic acid sequencing, and/orother similar techniques. The analysis can comprise determining thepresence and/or level of one or more biological substance in the one ormore biological samples. Once this analysis is complete, a diagnosisand/or treatment can be added.

Polymerase Chain Reaction (PCR)

The polymerase chain reaction (PCR) is a process for amplifying one ormore desired specific nucleic acid sequences found in a nucleic acid.Because large amounts of a specific sequence can be produced by thisprocess, it can be used for improving the efficiency of cloning DNA ormessenger RNA and for amplifying a target sequence to facilitatedetection thereof.

PCR involves a chain reaction for producing, in exponential quantitiesrelative to the number of reaction steps involved, at least one specificnucleic acid sequence given (a) that the ends of the required sequenceare known in sufficient detail that oligonucleotides can be synthesizedwhich will hybridize to them, and (b) that a small amount of thesequence is available to initiate the chain reaction. The product of thechain reaction would be a discrete nucleic acid duplex with terminicorresponding to the ends of the specific primers employed.

Any source of nucleic acid, in purified or non-purified form, can beutilized as the starting nucleic acid or acids, provided it contains oris suspected of containing the specific nucleic acid sequence desired.Thus, the process may employ, for example, DNA or RNA, includingmessenger RNA, which DNA or RNA can be single stranded or doublestranded. In addition, a DNA-RNA hybrid which contains one strand ofeach can be utilized. A mixture of any of these nucleic acids may alsobe employed, or the nucleic acid produced from a previous amplificationreaction herein using the same or different primers can be so utilized.The specific nucleic acid sequence to be amplified can be only afraction of a larger molecule or can be present initially as a discretemolecule, so that the specific sequence constitutes the entire nucleicacid. It is not necessary that the sequence to be amplified be presentinitially in a pure form; it can be a minor fraction of a complexmixture, such as a portion of the β-globin gene contained in whole humanDNA or a portion of nucleic acid sequence due to a particularmicroorganism which organism might constitute only a minor fraction of aparticular biological sample. The starting nucleic acid may contain morethan one desired specific nucleic acid sequence which can be the same ordifferent. Therefore, it is useful not only for producing large amountsof one specific nucleic acid sequence, but also for amplifyingsimultaneously more than one different specific nucleic acid sequencelocated on the same or different nucleic acid molecules.

The nucleic acid or acids can be obtained from any source, for example,from plasmids such as pBR322, from cloned DNA or RNA, or from naturalDNA or RNA from any source, including but not limited to, bacteria,yeast, viruses, and higher organisms such as plants or animals. DNA orRNA can be extracted from, including but not limited to, blood (wholeblood, plasma, serum), tissue material such as chorionic villi oramniotic cells. The DNA or RNA can be cell-free DNA or RNA.

It will be understood that the word primer as used may refer to morethan one primer, particularly in the case where there is some ambiguityin the information regarding the terminal sequence(s) of the fragment tobe amplified. For instance, in the case where a nucleic acid sequence isinferred from protein sequence information a collection of primerscontaining sequences representing all possible codon variations based ondegeneracy of the genetic code will be used for each strand. One primerfrom this collection can be 100% homologous with the end of the desiredsequence to be amplified.

An appropriate agent can be added for inducing or catalyzing the primerextension reaction and the reaction can be allowed to occur underconditions known in the art. The inducing agent can be any compound orsystem which will function to accomplish the synthesis of primerextension products, including, but not limited to, enzymes. Suitableenzymes for this purpose can include, for example, E. coli DNApolymerase I, Klenow fragment of E. coli DNA polymerase I, T4 DNApolymerase, other available DNA polymerases, reverse transcriptase, andother enzymes, including heat-stable enzymes, which will facilitatecombination of the nucleotides in the proper manner to form the primerextension products which are complementary to each nucleic acid strand.Generally, the synthesis can be initiated at the 3′ end of each primerand proceed in the 5′ direction along the template strand, untilsynthesis terminates, producing molecules of different lengths. Therecan be inducing agents, however, which initiate synthesis at the 5′ endand proceed in the other direction, using the same process as describedabove.

The newly synthesized strand and its complementary nucleic acid strandcan form a double-stranded molecule which can be used in the succeedingsteps of the process. In the next step, the strands of thedouble-stranded molecule can be separated to provide single-strandedmolecules. New nucleic acid can be synthesized on the single-strandedmolecules. Additional inducing agent, nucleotides and primers can beadded if necessary for the reaction to proceed under the conditionsprescribed above. Again, the synthesis can be initiated at one end ofthe oligonucleotide primers and can proceed along the single strands ofthe template to produce additional nucleic acid. After this step, halfof the extension product can consist of the specific nucleic acidsequence bounded by the two primers. The steps of strand separation andextension product synthesis can be repeated as often as needed toproduce the desired quantity of the specific nucleic acid sequence. Theamount of the specific nucleic acid sequence produced can accumulate inan exponential fashion. After the appropriate length of time has passedto produce the desired amount of the specific nucleic acid sequence, thereaction can be halted by inactivating the enzymes in any known manneror separating the components of the reaction.

Amplification can be useful when the amount of nucleic acid availablefor analysis is small, as, for example, in the prenatal diagnosis ofsickle cell anemia using DNA obtained from fetal cells or from maternalplasma/serum/blood. Amplification can be particularly useful if such ananalysis can be to be done on a small sample using non-radioactivedetection techniques that can be inherently insensitive, or whereradioactive techniques are employed but where rapid detection can bedesirable.

Any known techniques for nucleic acid (e.g., DNA and RNA) amplificationcan be used with the assays described herein. Some amplificationtechniques are the polymerase chain reaction (PCR) methodologies whichcan include, but are not limited to, solution PCR and in situ PCR.

The invention is not limited to the use of straightforward PCR. A systemof nested primers can be used for example. Other suitable amplificationmethods known in the field can also be applied such as, but not limitedto, ligase chain reaction (LCR), strand displacement amplification(SDA), self-sustained sequence replication (3SR), array based test,digital PCR, and TAQMAN.

As used herein “amplification” may refer to any in vitro method forincreasing the number of copies of a nucleic acid sequence, e.g., withthe use of a DNA polymerase. Nucleic acid amplification can result inthe incorporation of nucleotides into a DNA molecule or primer therebyforming a new DNA molecule complementary to a DNA template. The newlyformed DNA molecule and its template can be used as templates tosynthesize additional DNA molecules. As used herein, one amplificationreaction may consist of many rounds of DNA replication. DNAamplification reactions can include, for example, polymerase chainreactions (PCR). One PCR reaction may consist of 5-100 “cycles” ofdenaturation, annealing, and synthesis of a DNA molecule.

Nucleic Acid Sequencing

Nucleic acid sequencing can be used for detection of a biologicalsubstance in a biological sample. Nucleic acid sequencing enablesdetection of the presence or absence of nucleic acids, determining thelevels of nucleic acids, and also determining the exact nucleotidesequences. The methods can be performed by any known methods, forexample, Maxam-Gilbert sequencing, Sanger sequencing, shotgunsequencing, bridge PCR, massively parallel signature sequencing (MPSS),polony sequencing, 454 pyrosequencing, Illumina (Solexa) sequencing,SOLiD sequencing, Ion Torrent semiconductor sequencing, DNA nanoballsequencing, heliscope single molecule sequencing, and/or single moleculereal time (SMRT) sequencing. Other sequencing methods can be used suchas nanopore DNA sequencing, tunnelling currents DNA sequencing,sequencing by hybridization, sequencing with mass spectrometry,microfluidic Sanger sequencing, microscopy-based techniques, RNAPsequencing, and/or in vitro virus high-throughput sequencing. Thesemethods are disclosed in the literature.

Fluorescence Microscopy

Fluorescence microscopy can be used for detection of a biologicalsubstance in a biological sample. Fluorescence microscopy can enable themolecular composition of the structures being observed to be identifiedthrough the use of fluorescently-labeled probes of high chemicalspecificity such as antibodies. It can be done by directly conjugating afluorophore to a protein and introducing this back into a cell.Fluorescent analogs can behave like the native protein and can thereforeserve to reveal the distribution and behavior of this protein in thecell. Along with NMR, infrared spectroscopy, circular dichroism andother techniques, protein intrinsic fluorescence decay and itsassociated observation of fluorescence anisotropy, collisional quenchingand resonance energy transfer are techniques for protein detection.Microscopy can also be used to detect and enumerate cells, such aseosinophils.

The naturally fluorescent proteins can be used as fluorescent probes.The jellyfish aequorea victoria produces a naturally fluorescent proteinknown as green fluorescent protein (GFP). The fusion of thesefluorescent probes to a target protein enables visualization byfluorescence microscopy and quantification by flow cytometry. Withoutlimiting the scope of the present invention, some of the probes are asfollowing:

Labels: Sensitivity and safety (compared to radioactive methods) offluorescence has led to an increasing use for specific labeling ofnucleic acids, proteins and other biomolecules. Besides fluorescein,other fluorescent labels cover the whole range from 400 to 820 nm. Byway of example only, some of the labels can be: fluorescein and itsderivatives, carboxyfluoresceins, rhodamines and their derivatives, attolabels, fluorescent red and fluorescent orange: Cy3/Cy5 alternatives,lanthanide complexes with long lifetimes, long wavelength labels—up to800 nm, DY cyanine labels, and phycobili proteins.

Conjugates: Antibody conjugates can be generated with specificity forvirtually any epitope and are therefore, applicable to imaging a widerange of biomolecules. By way of example only, some of the conjugatescan be: isothiocyanate conjugates, streptavidin conjugates, and/orbiotin conjugates.

Enzyme Substrates: By way of example only, some of the enzyme substratescan be fluorogenic and chromogenic substrates.

Micro- and Nanoparticles: By way of example only, some of thefluorochromes can be: FITC (green fluorescence,excitation/emission=506/529 nm), rhodamine B (orange fluorescence,excitation/emission=560/584 nm), and nile blue A (red fluorescence,excitation/emission=636/686 nm). Fluorescent nanoparticles can be usedfor various types of immunoassays. Fluorescent nanoparticles can bebased on different materials, such as, polyacrylonitrile, andpolystyrene etc.

Molecular Rotors: Fluorescent molecular rotors are sensors ofmicroenvironmental restriction that become fluorescent when theirrotation is constrained. Few examples of molecular constraint caninclude increased dye (aggregation), binding to antibodies, or beingtrapped in the polymerization of actin.

IEF-Markers: IEF (isoelectric focusing) is an analytical tool for theseparation of ampholytes, mainly proteins. An advantage for IEF-Gelelectrophoresis with fluorescent IEF-marker is the possibility todirectly observe the formation of gradient. Fluorescent IEF-marker canalso be detected by UV-absorption at 280 nm (20° C.).

Any or all of these fluorescent probes can be used for the detection ofbiological substances in the nasal mucus. A peptide library can besynthesized on solid supports and, by using coloring receptors,subsequent dyed solid supports can be selected one by one. If receptorscannot indicate any color, their binding antibodies can be dyed. Themethods can not only be used on protein receptors, but also on screeningbinding ligands of synthesized artificial receptors and screening newmetal binding ligands as well. Automated methods for HTS and FACS(fluorescence activated cell sorter) can also be used. A FACS machineoriginally runs cells through a capillary tube and separate cells bydetecting their fluorescent intensities.

Immunoassays

Immunoassay can be used for detecting a biological substance in abiological sample. In immunoblotting like the western blot ofelectrophoretically separated proteins a single protein can beidentified by its antibody. Immunoassay can be competitive bindingimmunoassay where analyte competes with a labeled antigen for a limitedpool of antibody molecules (e.g., radioimmunoassay, EMIT). Immunoassaycan be non-competitive where antibody is present in excess and islabeled. As analyte antigen complex is increased, the amount of labeledantibody-antigen complex may also increase (e.g., ELISA). Antibodies canbe polyclonal if produced by antigen injection into an experimentalanimal, or monoclonal if produced by cell fusion and cell culturetechniques. In immunoassay, the antibody may serve as a specific reagentfor the analyte antigen.

Without limiting the scope and content of the present invention, some ofthe types of immunoassays can be, by way of example only, RIAs(radioimmunoassay), enzyme immunoassays like ELISA (enzyme-linkedimmunosorbent assay), EMIT (enzyme multiplied immunoassay technique),microparticle enzyme immunoassay (MEIA), LIA (luminescent immunoassay),and FIA (fluorescent immunoassay). These techniques can be used todetect biological substances in the nasal specimen. Theantibodies—either used as primary or secondary ones—can be labeled withradioisotopes (e.g., 125I), fluorescent dyes (e.g., FITC) or enzymes(e.g., HRP or AP) which may catalyze fluorogenic or luminogenicreactions.

EMIT (Enzyme Multiplied Immunoassay Technique): EMIT is a competitivebinding immunoassay that avoids a separation step. EMIT is a type ofimmunoassay in which the protein can be labeled with an enzyme, and theenzyme-protein-antibody complex can be enzymatically inactivated,allowing quantitation of unlabeled protein.

ELISA (Enzyme Linked Immunosorbent Assay): The invention can also useELISA to detect biological substances in the nasal specimen. ELISA isbased on selective antibodies attached to solid supports combined withenzyme reactions to produce systems capable of detecting low levels ofproteins. It is also known as enzyme immunoassay or EIA. The protein canbe detected by antibodies that have been made against it, that is, forwhich it is the antigen. Monoclonal antibodies are often used.

The test may require the antibodies to be fixed to a solid surface, suchas the inner surface of a test tube, and a preparation of the sameantibodies coupled to an enzyme. The enzyme can be one (e.g.,β-galactosidase) that produces a colored product from a colorlesssubstrate. The test, for example, can be performed by filling the tubewith the antigen solution (e.g., protein) to be assayed. Any antigenmolecules present may bind to the immobilized antibody molecules. Theantibody-enzyme conjugate can be added to the reaction mixture. Theantibody part of the conjugate binds to any antigen molecules that werebound previously, creating an antibody-antigen-antibody “sandwich”.After washing away any unbound conjugate, the substrate solution can beadded. After a set interval, the reaction can be stopped (e.g., byadding 1 N NaOH) and the concentration of colored product formed can bemeasured in a spectrophotometer. The intensity of color can beproportional to the concentration of bound antigen.

ELISA can also be adapted to measure the concentration of antibodies, inwhich case, the wells can be coated with the appropriate antigen. Thesolution (e.g., serum) containing antibody can be added. After it hashad time to bind to the immobilized antigen, an enzyme-conjugatedanti-immunoglobulin can be added, consisting of an antibody against theantibodies being tested for. After washing away unreacted reagent, thesubstrate can be added. The intensity of the color produced can beproportional to the amount of enzyme-labeled antibodies bound (and thusto the concentration of the antibodies being assayed).

Radioimmunoassay: Some embodiments of the invention can includeradioimmunoassays to detect biological substances in the biologicalsamples, e.g., in the nasal specimen. Radioactive isotopes can be usedto study in vivo metabolism, distribution, and binding of small amountof compounds. Radioactive isotopes of ¹H, ¹²C, ³¹P, ³²S, and ¹²⁷I inbody can be used, such as ³H, ¹⁴C, ³²P, ³⁵S, and ¹²⁵I.

In receptor fixation method in 96-well plates, receptors can be fixed ineach well by using antibody or chemical methods and radioactive labeledligands can be added to each well to induce binding. Unbound ligands canbe washed out and then the standard can be determined by quantitativeanalysis of radioactivity of bound ligands or that of washed-outligands. Then, addition of screening target compounds may inducecompetitive binding reaction with receptors. If the compounds showhigher affinity to receptors than standard radioactive ligands, most ofradioactive ligands would not bind to receptors and can be left insolution. Therefore, by analyzing quantity of bound radioactive ligands(or washed-out ligands), testing compounds' affinity to receptors can beindicated.

The filter membrane method can be needed when receptors cannot be fixedto 96-well plates or when ligand binding needs to be done in solutionphase. In other words, after ligand-receptor binding reaction insolution, if the reaction solution can be filtered throughnitrocellulose filter paper, small molecules including ligands may gothrough it and only protein receptors can be left on the paper. Onlyligands that strongly bound to receptors may stay on the filter paperand the relative affinity of added compounds can be identified byquantitative analysis of the standard radioactive ligands.

Fluorescence Immunoassays: The invention can also include fluorescenceimmunoassays for detecting a biological substance in a biologicalsample. Fluorescence based immunological methods can be based upon thecompetitive binding of labeled ligands versus unlabeled ones on highlyspecific receptor sites. Fluorescence immunoassays can also be used todetect and enumerate cells, such as eosinophils.

The fluorescence technique can be used for immunoassays based on changesin fluorescence lifetime with changing analyte concentration. Thistechnique may work with short lifetime dyes like fluoresceinisothiocyanate (FITC) (the donor) whose fluorescence can be quenched byenergy transfer to eosin (the acceptor). A number of photoluminescentcompounds can be used, such as cyanines, oxazines, thiazines,porphyrins, phthalocyanines, fluorescent infrared-emitting polynucleararomatic hydrocarbons, phycobiliproteins, squaraines and organo-metalliccomplexes, hydrocarbons and azo dyes.

Fluorescence based immunological methods can be, for example,heterogenous or homogenous. Heterogenous immunoassays can comprisephysical separation of bound from free labeled analyte. The analyte orantibody can be attached to a solid surface. The technique can becompetitive (for a higher selectivity) or noncompetitive (for a highersensitivity). Detection can be direct (only one type of antibody used)or indirect (a second type of antibody can be used). Homogenousimmunoassays can comprise no physical separation. Double-antibodyfluorophore—labeled antigen can participate in an equilibrium reactionwith antibodies directed against both the antigen and the fluorophore.Labeled and unlabeled antigen may compete for a limited number ofanti-antigen antibodies.

Some of the fluorescence immunoassay methods can include simplefluorescence labeling method, fluorescence resonance energy transfer(FRET), time resolved fluorescence (TRF), and scanning probe microscopy(SPM). The simple fluorescence labeling method can be used forreceptor-ligand binding, enzymatic activity by using pertinentfluorescence, and as a fluorescent indicator of various in vivophysiological changes such as pH, ion concentration, and electricpressure. TRF is a method that can selectively measure fluorescence ofthe lanthanide series after the emission of other fluorescent moleculesis finished. TRF can be used with FRET and the lanthanide series canbecome donors or acceptors. In scanning probe microscopy, in the capturephase, for example, at least one monoclonal antibody can adhere to asolid phase and a scanning probe microscope can be utilized to detectantigen/antibody complexes which can be present on the surface of thesolid phase. The use of scanning tunneling microscopy can eliminate theneed for labels which normally can be utilized in many immunoassaysystems to detect antigen/antibody complexes.

Nuclear Magnetic Resonance (NMR)

The invention can also include NMR for detecting a biological substancein a biological sample. NMR spectroscopy can determine the structures ofbiological macromolecules like proteins and nucleic acids at atomicresolution. In addition, it can be possible to study time dependentphenomena with NMR, such as intramolecular dynamics in macromolecules,reaction kinetics, molecular recognition or protein folding.Heteronuclei like ¹⁵N, ¹³C and ²H, can be incorporated in proteins byuniform or selective isotopic labeling. Additionally, some newinformation about structure and dynamics of macromolecules can bedetermined with these methods.

X-Ray Crystallography

The invention can also include X-ray crystallography for detecting abiological substance in a biological sample. X-ray crystallography is atechnique in which the pattern produced by the diffraction of X-raysthrough the closely spaced lattice of atoms in a crystal is recorded andthen analyzed to reveal the nature of that lattice. This generally canlead to an understanding of the material and molecular structure of asubstance. The spacing in the crystal lattice can be determined usingBragg's law. X-ray diffraction can be commonly carried out using singlecrystals of a material, but if these are not available, microcrystallinepowdered samples may also be used which may require different equipment.

Fluorescence Spectroscopy

The invention can also include fluorescence spectroscopy for detecting abiological substance in a biological sample. By way of example only,conventional fluorometry is measurement of emission light intensities atdefined wavelengths for a certain emission maxima of a fluorophore.Total fluorometry is a collection of data for a continuum of absorptionas well as emission wavelengths. Fluorescence polarization is whenpolarized light is used for excitation and binding offluorochrome-labeled antigens to specific antibodies. Line narrowingspectroscopy is low-temperature solid-state spectroscopy that derivesits selectivity from the narrow-line emission spectra.

Time-dependent fluorescence spectroscopy can comprise time-resolvedmeasurements containing more information than steady-state measurements,since the steady-state values represent the time average oftime-resolved determinations. It is a single photon timing techniquewhere the time between an excitation light pulse and the first photonemitted by the sample is measured.

Matrix Assisted Laser Desorption Ionization Time-of-Flight MassSpectrometry (MALDI TOF-MS)

The invention can include MALDI TOF-MS for detecting a biologicalsubstance in a biological sample. MALDI TOF-MS provides accurate massdeterminations and primary sequence information. Improved massresolution in MALDI TOF-MS can be obtained by the utilization of asingle-stage or a dual-stage reflectron (RETOF-MS). In the reflectronmass spectrum, the isotopic multiplet can be well resolved producing afull width half maximum (FWHM) mass resolution of about 3400. Massresolutions up to 6000 (FWHM) can be obtained for peptides up to about3000 Da with RETOF-MS. Enhancing the mass resolution can also increasethe mass accuracy when determining the ion's mass.

Both linear and reflectron MALDI-TOF-MS can be utilized for molecularweight determinations of molecular ions and enzymatic digests leading tostructural information of proteins. These digests are typically massanalyzed with or without purification prior to molecular weightdeterminations. Varieties of methodologies have been developed to obtainprimary sequence information for proteins and peptides utilizing MALDITOF-MS. Two different approaches can be taken. The first method is knownas protein ladder sequencing and can be employed to produce structurallyinformative fragments of the analyte prior to insertion into the TOFmass spectrometer and subsequent analysis. The second approach canutilize the phenomenon of metastable ion decay that occurs inside theTOF mass spectrometer to produce sequence information.

The ladder sequencing with TOF-MS consists of either a time-dependent orconcentration-dependent chemical degradation from either the N- orC-terminus of the protein/peptide into fragments, each of which differsby one amino acid residue. The mixture can be mass analyzed in a singleMALDI-TOF-MS experiment with mass differences between adjacent massspectral peaks corresponding to a specific amino acid residue. The orderof occurrence in the mass spectrum defines the sequence of amino acidsin the original protein/peptide.

Post-source decay with RETOF-MS MALDI is an ionization technique thatproduces intact protonated pseudomolecular ion species. A significantdegree of metastable ion decay can occur after ion acceleration andprior to detection. The ion fragments produced from the metastable iondecay of peptides and proteins typically can include both neutralmolecule losses (such as water, ammonia and portions of the amino acidside chains) and random cleavage at peptide bonds. In-source decay withlinear TOF-MS is an alternative approach to RETOF-MS for studyingmetastable ion decay of MALDI generated ions. Primary structuralinformation for peptides and proteins can be obtained by this method.Coherent mass spectral peaks can be produced from these metastabledecayed ions giving rise to significant structural information forpeptides and proteins.

Surface-Enhanced Laser Desorption Ionization—Time Offlight (SELDI-TOF)

The invention can include SELDI TOF-MS for detecting a biologicalsubstance in a biological sample. This technique can utilize stainlesssteel or aluminum-based supports, or chips, engineered with chemical(hydrophilic, hydrophobic, pre-activated, normal-phase, immobilizedmetal affinity, and cationic or anionic) or biological (antibody,antigen binding fragments (e.g., scFv), DNA, enzyme, or receptor) baitsurfaces of 1-2 mm in diameter. These varied chemical and biochemicalsurfaces can allow differential capture of proteins based on theintrinsic properties of the proteins themselves. Solubilized tissue orbody fluids in volumes as small as 0.1 μl can be directly applied tothese surfaces, where proteins with affinities to the bait surface maybind. Following a series of washes to remove non-specifically or weaklybound proteins, the bound proteins can be laser desorbed and ionized forMS analysis. Masses of proteins ranging from small peptides of less than1000 Da up to proteins of greater than 300 kDa can be calculated basedon time-of-flight. As mixtures of proteins can be analyzed withindifferent samples, a unique sample fingerprint or signature may resultfor each sample tested. Consequently, patterns of masses rather thanactual protein identifications can be produced by SELDI analysis. Thesemass spectral patterns can be used to differentiate patient samples fromone another, such as diseased from normal.

UV-Vis

The invention can include optical absorption spectroscopy (UV/VIS) fordetecting a biological substance in a biological sample. UV/VIS provideslight absorption data which helps in the determination of concentrationof macromolecules such as, proteins, DNA, nucleotides etc. Organic dyescan be used to enhance the absorption and to shift the absorption intothe visible range (e.g., coomassie blue reagents). Resonance ramanspectroscopy (RRS) can be used to study molecular structure anddynamics. RRS helps in investigating specific parts of macromolecules byusing different excitation wavelengths.

Liquid Chromatography (LC)

The invention can include LC for detecting a biological substance in abiological sample. Examples of LC are but not limited to, affinitychromatography, gel filtration chromatography, anion exchangechromatography, cation exchange chromatography, diode array-LC and highperformance liquid chromatography (HPLC).

Gel filtration chromatography can separate proteins, peptides, andoligonucleotides on the basis of size. Molecules may move through a bedof porous beads, diffusing into the beads to greater or lesser degrees.Smaller molecules may diffuse further into the pores of the beads andtherefore move through the bed more slowly, while larger molecules mayenter less or not at all and thus move through the bed more quickly.Both molecular weight and three dimensional shapes contribute to thedegree of retention. Gel Filtration Chromatography can be used foranalysis of molecular size, for separations of components in a mixture,or for salt removal or buffer exchange from a preparation ofmacromolecules.

Affinity chromatography is the process of bioselective adsorption andsubsequent recovery of a compound from an immobilized ligand. Thisprocess can allow for the specific and efficient purification of manydiverse proteins and other compounds. Ion exchange chromatography canseparate molecules based on differences between the overall charges ofthe proteins. It can be used for the purification of protein,oligonucleotides, peptides, or other charged molecules.

HPLC can be used in the separation, purification and detection ofbiological substances in the nasal mucus. Crude tissue extracts can beloaded directly onto the HPLC system and mobilized by gradient elution.Rechromatography under the identical conditions can be an option iffurther purification is warranted or necessary. Reversed phasechromatography (RPC) can be utilized in the process of protein structuredetermination. HPLC can be coupled with MS. The HPLC method described inHenkin et al., New Frontiers in Immunobiology, 2000, pp. 127-152, isincorporated herein in its entirety.

The size-exclusion chromatography (SEC) and ion-exchange chromatography(IEC) can be used for separation and purification of biologically activeproteins, such as enzymes, hormones, and antibodies. In liquid affinitychromatography (LAC), interaction can be based on binding of the proteindue to mimicry of substrate, receptor, etc. The protein can be eluted byintroducing a competitive binding agent or altering the proteinconfiguration which may facilitate dissociation. A procedure that can beused in the separation of membrane proteins is the use of nonionicdetergents, such as Triton X-100, or protein solubilization by organicsolvents with IEC.

Diode array detector-liquid chromatography (DAD-LC) provides complete,multiple spectra for each HPLC peak, which, by comparison, can provideindication of peak purity. These data can also assign presence of tyr,trp, phe, and possibly others (his, met, cys) and can quantitate theseamino acids by 2nd derivative or multi-component analysis. By apost-column derivatization, DAD-LC can also identify and quantitate cys,his and arg in individual peptides. Thus, it can be possible to analyzefor 6 of the 20 amino acids of each separated peptide in a single LCrun, and information can be obtained about presence or absence of theseamino acids in a given peptide in a single step. This can be assisted byknowing the number of residues in each peptide.

Electrophoresis

The invention can include electrophoresis for detecting a biologicalsubstance in a biological sample. Electrophoresis can be gelelectrophoresis or capillary electrophoresis.

Gel Electrophoresis: Gel electrophoresis is a technique that can be usedfor the separation of proteins. During electrophoresis, macromoleculesare forced to move through pores when an electrical current is applied.Their rate of migration through the electric field depends on strengthof the field, size and shape of the molecules, relative hydrophobicityof the samples, and on an ionic strength and temperature of a buffer inwhich the molecules are moving. After staining, the separatedmacromolecules in each lane can be seen in a series of bands spread fromone end of the gel to the other. Using this technology can be possibleto separate and identify protein molecules that differ by as little as asingle amino acid. Also, gel electrophoresis can allow determination ofcrucial properties of a protein such as its isoelectric point andapproximate molecular weight. Electrofocusing or isoelectric focusing isa technique for separating different molecules by their electric chargedifferences (if they have any charge). It is a type of zoneelectrophoresis that takes advantage of the fact that a molecule'scharge changes as the pH of its surroundings changes.

Capillary Electrophoresis: Capillary electrophoresis is a collection ofa range of separation techniques which may involve the application ofhigh voltages across buffer filled capillaries to achieve separations.The variations can include separation based on size and chargedifferences between analytes (termed capillary zone electrophoresis(CZE) or free solution CE (FSCE)), separation of neutral compounds usingsurfactant micelles (micellar electrokinetic capillary chromatography(MECC) or sometimes referred to as MEKC) sieving of solutes through agel network (capillary gel electrophoresis, GCE), separation of cations(or anions) based on electrophoretic mobility (capillaryisotachophoresis, CITP), and separation of zwitterionic solutes within apH gradient (capillary isoelectric focusing, CLEF). Capillaryelectrochromatography (CEC) can be an associated electrokineticseparation technique which involves applying voltages across capillariesfilled with silica gel stationary phases. Separation selectivity in CECcan be any combination of both electrophoretic and chromatographicprocesses. Many of the CE separation techniques can rely on the presenceof an electrically induced flow of solution (electroosmotic flow, EOF)within the capillary to pump solutes towards the detector.

Arrays

The invention can include arrays for detecting a biological substance ina biological sample. Arrays can involve performing parallel analysis ofmultiple samples against known protein targets. The development ofvarious microarray platforms can enable and accelerate the determinationof protein abundance, localization, and interactions in a cell ortissue. Microarrays can provide a platform that allows identification ofprotein interaction or function against a characterized set of proteins,antibodies, or peptides. Protein-based chips can array proteins on asmall surface and can directly measure the levels of proteins in tissuesusing fluorescence-based imaging. Proteins can be arrayed on either flatsolid phases or in capillary systems (microfluidic arrays), and severaldifferent proteins can be applied to these arrays. In addition to theuse of antibodies as array probes, single-stranded oligonucleotides,whose specificity is optimized by in vitro elution (aptamers), offer aviable alternative. Nonspecific protein stains can be then used todetect bound proteins.

Arrays can include, but are not limited to, bead arrays, bead basedarrays, bioarrays, bioelectronic arrays, cDNA arrays, cell arrays, DNAarrays, gene arrays, gene expression arrays, frozen cell arrays, genomearrays, high density oligonucleotide arrays, hybridization arrays,microcantilever arrays, microelectronic arrays, multiplex DNAhybridization arrays, nanoarrays, oligonucleotide arrays,oligosaccharide arrays, planar arrays, protein arrays, solution arrays,spotted arrays, tissue arrays, exon arrays, filter arrays, macroarrays,small molecule microarrays, suspension arrays, theme arrays, tilingarrays, and transcript arrays.

Sensors

The invention can include sensors for detecting a biological substancein a biological sample. Sensors can be used for both in vivo and invitro detection. Sensors can be chemical sensors, optical sensors, andbiosensors. Chemical sensors can be miniaturized analytical deviceswhich may deliver real-time and online information on the presence ofspecific compounds or ions in complex samples. Optical sensors can bebased on measurement of either intrinsic optical properties of analytes,or of optical properties of indicator dyes or labeled biomoleculesattached to solid supports. Biosensors can be affinity biosensor basedon capabilities of enzymes to convert substrates into products orcatalytic biosensors. Biosensors can detect antibody and analytecomplexes using a variety of physical methods. Some biosensors canmeasure the change in surface charge that occurs when analyte is boundto antibodies or other binding agents, which in turn are bound to asurface. Other biosensors can use binding agents attached to a surfaceand measure a change in a physical property of the support, other thansurface charge, upon binding of analyte. Some biosensor techniques canuse a specific property of a labeled binding agent or antigen to producea measurable change.

Methods for Identifying Proteins from a Library Screen

Protein identification methods by way of example only can includelow-throughput sequencing through Edman degradation, mass spectrometrytechniques, peptide mass fingerprinting, de novo sequencing, andantibody-based assays. The protein quantification assays can includefluorescent dye gel staining, tagging or chemical modification methods(i.e., isotope-coded affinity tags (ICATS), combined fractional diagonalchromatography (COFRADIC)). The purified protein may also be used fordetermination of three-dimensional crystal structure, which can be usedfor modeling intermolecular interactions. Common methods for determiningthree-dimensional crystal structure can include x-ray crystallographyand NMR spectroscopy. Detailed below are a few of the methods foridentifying proteins in the present invention.

Protein sequencing: N-terminal sequencing can aid in the identificationof unknown proteins, can confirm recombinant protein identity andfidelity (reading frame, translation start point, etc.), can aid theinterpretation of NMR and crystallographic data, can demonstrate degreesof identity between proteins, or can provide data for the design ofsynthetic peptides for antibody generation, etc. N-terminal sequencingcan utilize the Edman degradative chemistry, sequentially removing aminoacid residues from the N-terminus of the protein and identifying them byreverse-phase HPLC. Sensitivity can be at the level of 100 s femtomolesand long sequence reads (20-40 residues) can often be obtained from afew 10 s picomoles of starting material. Pure proteins (>90%) cangenerate easily interpreted data, but insufficiently purified proteinmixtures may also provide useful data, subject to rigorous datainterpretation. N-terminally modified (especially acetylated) proteinscannot be sequenced directly, as the absence of a free primaryamino-group prevents the Edman chemistry. However, limited proteolysisof the blocked protein (e.g., using cyanogen bromide) may allow amixture of amino acids to be generated in each cycle of the instrument,which can be subjected to database analysis in order to interpretmeaningful sequence information. C-terminal sequencing can be apost-translational modification, affecting the structure and activity ofa protein. Various disease situations can be associated with impairedprotein processing and C-terminal sequencing provides an additional toolfor the investigation of protein structure and processing mechanisms.

Proteome analyses: Proteomics can be identified primarily by computersearch algorithms that assign sequences to a set of empirically acquiredmass/intensity data which are generated from conducting electrosprayionization (ESI), matrix-assisted laser desorption/ionization(MALDI-TOF), or three-dimensional quadrupole ion traps on the protein ofinterest.

Diagnosis

Generally, the compositions and methods of this disclosure can providefor the diagnosis or treatment of smell loss and/or distortion (e.g.,hyposmia, dysosmia, anosmia) and/or taste loss and/or distortion (e.g.,hypogeusia, dysgeusia, ageusia) by detecting one or more members of thehedgehog signaling pathway in one or more biological samples.

Examples of Biological Substances

Various substances that can be analyzed and/or measured in the methodsdisclosed herein can include, by way of example only, proteins,carbohydrates, lipids, hormones (e.g., leptin, ghrelin) in control ofappetite, cholesterol and other lipids and lipid carrying proteins incontrol of lipid metabolism, growth factors (e.g., hepatic growthfactor, granulocyte colony growth factor, brain derived neurotrophicfactor), and antibodies, liver enzymes (e.g., SGOT, SGPT) therapeuticand recreational drugs of abuse, trace metals [either excess as intoxicity (e.g., lead, mercury, arsenic) or in deficiency diseasesinvolving zinc, copper, magnesium] and most other substances found inplasma, erythrocytes, urine, saliva, and perspiration. Each metabolitein nasal mucus may reflect both physiological and pathological changesin human body metabolism specific to each metabolite and may reflect themanner in which nasal mucus provides information both on human bodymetabolism such as provided by plasma, erythrocytes, urine, saliva, andperspiration or information relatively unique to nasal mucus.

Biological substances can comprise one or more members of the hedgehogsignaling pathway selected from a group consisting of SHH, DHH, and IHH.The level of one or more members of the hedgehog signaling pathway canindicate whether a subject has loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia.

Biological substances can comprise cytokines, such a pro-inflammatorycytokines or anti-inflammatory cytokines. Pro-inflammatory cytokines caninclude IL-1α, IL-1β, IL-6, IL-18, TNF-α, or any combination thereof.Anti-inflammatory cytokines can include IL-1ra, IL-10, IFN-γ, IFN-β, orany combination thereof. The balance of pro- and anti-inflammatorycytokines can indicate whether a subject has loss and/or distortion oftaste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia,hypogeusia, dysgeusia, phantogeusia, and/or ageusia.

Biological substances can comprise cytokine receptors such as type Icytokine receptors, type II cytokine receptors, members of theimmunoglobulin superfamily, members of the tumor necrosis factorreceptor family, chemokine receptors, and or TGF-beta receptors. Forexample, a cytokine receptor can be IL-1 RII and/or IL-2R.

Biological substances can comprise eosinophils. Biological substancescan comprise IgE protein. Biological substances can comprise cyclicnucleotides (e.g., cAMP, cGMP). Biological substances can comprisenitric oxide (NO).

The identification and analysis of biological substances as disclosedherein can have numerous therapeutic and diagnostic applications.Clinical applications can include, for example, detection of loss and/ordistortion of taste or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia;distinguishing the underlying cause of the loss and/or distortion oftaste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia,hypogeusia, dysgeusia, phantogeusia, and/or ageusia to inform prognosis,selection of therapy, and/or prediction of therapeutic response;monitoring of therapy associated with efficacy and toxicity; anddetection of recurrence of the loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia.

The presence or increase or decrease of biological substances'concentration can allow the physician to diagnose loss and/or distortionof taste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia,hypogeusia, dysgeusia, phantogeusia, and/or ageusia and/or to predictthe efficacy of treatment regimes.

The diagnosis of loss and/or distortion of taste or smell, e.g.,hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia as disclosed herein can be used to enableor assist in the pharmaceutical drug development process for therapeuticagents. The analysis can be used to diagnose patients enrolling in aclinical trial. The diagnosis can indicate the state of the loss and/ordistortion of taste or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia inpatients undergoing treatment in clinical trials, and show changes inthe state during the treatment. The diagnosis can demonstrate theefficacy of a treatment, and can be used to stratify patients accordingto their responses to various therapies.

The methods herein can be used to evaluate the efficacy of treatmentsover time. For example, biological samples can be obtained from apatient over a period of time as the patient is undergoing treatment.The biological substances from the different samples can be compared toeach other to determine the efficacy of the treatment. Also, the methodsdescribed herein can be used to compare the efficacies of differenttherapies and/or responses to one or more treatments in differentpopulations (e.g., different age groups, ethnicities, family histories,cause of loss and/or distortion of taste or smell, etc.).

General Methods for Diagnosis

Generally, the compositions and methods of this disclosure can providefor evaluating a subject's gustatory and/or olfactory function bydetermining a detection threshold (DT) score, a recognition threshold(RT) score, a magnitude estimation (ME) score, or any combinationthereof. These score can be determined as previously described inHenkin, R. I., Schecter, P. J., Friedewald, W. T., DeMets, D. L., Raff,M. S, incorporated herein by reference in its entirety. A double blindstudy of the effects of zinc sulfate on taste or smell dysfunction.Amer. J. Med. Sci. 1976; 272:285-299, incorporated herein by referencein its entirety. Some methods are described in Henkin, R. I., Levy, L.M., and Fordyce, A. Taste and smell function in chronic disease: areview of clinical and biochemical evaluations of taste and smelldysfunction in over 5000 patients at The Taste and Smell Clinic inWashington, D.C. Am. J. Otolaryngol. 2013 September-October;34(5):477-489, incorporated herein by reference in its entirety.

For example, patients can be initially diagnosed with suspectedhyposmia, if their sensory dysfunction manifests as either loss of taste(i.e., flavor) and/or smell function. This subjective response can bedocumented by objective psychophysical measurements of olfactoryfunction administered to each patient by use of a forced-choice,three-stimuli, stepwise-staircase technique in a fixed, controlleddesign as previously described herein and in Henkin, R. I. Evaluationand treatment of human olfactory dysfunction, in Otolaryngology(English, G. M. Ed.), Lippincott, Philadelphia, 1993, Vol. 2, pp. 1-86(incorporated by reference herein in its entirety).

In some cases four test odors can be used; they can be pyridine(dead-fish odor), nitrobenzene (bitter-almond odor), thiophene(petroleum-like odor) and amyl acetate (banana-oil odor). Detectionthresholds (DT), recognition thresholds (RT) and magnitude estimation(ME) values for each odor can be determined as previously described.Thresholds can be converted into bottle units (BU) as previouslydescribed and results reported as M±SEM of correct responses for eachodor in each treatment group; ME can be reported in % and resultscalculated to obtain M±SEM for each treatment group for all correctresponses using data for the four highest odor concentrations presented(from 10^(−2M)—an absolute odor concentration).

In addition, each patient can be graded using the hedonic (H) value ofeach odor presented for these same odor concentrations (from 10^(−2M)—anabsolute odor concentration using a −100-0-+100 scale). If they considera pleasant odor pleasant (“they wished to smell the odor again”) theycan be graded the odor as +1-+100 with respect to pleasantness; if theyconsider the odor unpleasant (“they did not wish to smell the odoragain”) they graded the odor as −1-−100 with respect to unpleasantness;if they do not consider the odor either pleasant or unpleasant they canbe graded the odor as neutral or 0. Results can be obtained bycalculating the arithmetical sum of each correct recognition responsefor each odor with respect to its pleasantness, unpleasantness orneutrality. Arithmetic M±SEM can be obtained for each treatment groupfor each odor presented. These score may then be compared to a referenceor threshold levels. This comparison can be used in aiding the diagnosisof hyposmia. Some methods are described in Henkin, R. I., Levy, L. M.,and Fordyce, A. Taste and smell function in chronic disease: a review ofclinical and biochemical evaluations of taste and smell dysfunction inover 5000 patients at The Taste and Smell Clinic in Washington, D.C. Am.J. Otolaryngol. 2013 September-October; 34(5):477-489, incorporatedherein by reference in its entirety.

Additionally, the present disclosure can provide for the measurement oflevels of one or more biological substances associated with loss and/ordistortion of taste or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia. Theselevels may also be compared to a threshold level, wherein the comparisoncan be also used to aid in the diagnosis of loss and/or distortion oftaste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia,hypogeusia, dysgeusia, phantogeusia, and/or ageusia. The level of thesebiological substances can include but not be limited to the level of oneor more members of the hedgehog signaling pathway.

For example, these members of the hedgehog signaling pathway can be SHH,DHH, and/or IHH, and/or any combination thereof can be decreased oreliminated. In some cases the hedgehog member can be SHH, DHH, IHH, orany combination thereof. The threshold for determining a decrease of thelevel of SHH in biological fluids can vary, for example, SHH levels canbe or about: 0 pg/mL, greater than 0 pg/mL to less than less than 1pg/mL, 1 pg/mL to 25 pg/mL, 15 pg/mL to 30 pg/mL, 20 pg/mL to 40 pg/mL;35 pg/mL to 50 pg/mL; 45 pg/mL to 100 pg/mL; 75 pg/mL to 150 pg/mL, 125pg/mL to 1000 pg/mL, 900 pg/mL to 2500 pg/mL, 2000 pg/mL to 5000 pg/mL,4000 pg/mL to 7500 pg/mL, 6000 pg/mL to 10,000 pg/mL. The threshold fordetermining a decrease of the level of DHH in biological fluids canvary, for example, DHH can be or about: 0 pg/mL, greater than 0 pg/mL to0.1 pg/mL, 0.05 pg/mL to 0.15 pg/mL, 0.125 pg/mL to 0.2 pg/mL, 0.15pg/mL to 0.30 pg/mL, 0.25 pg/mL to 0.5 pg/mL, 0.4 pg/mL to 0.7 pg/mL,0.6 pg/mL to 0.75 pg/mL, 0.725 pg/mL to 0.9 pg/mL, 0.8 pg/mL to 1.0pg/mL, 0.9 pg/mL to 1.1 pg/mL, 1.0 pg/mL to 1.3 pg/mL, 1.2 pg/mL to 1.5pg/mL, 1.4 pg/mL to 2.0 pg/mL, 1.9 pg/mL to 2.5 pg/mL, 2.4 pg/mL to 3.0pg/mL, 2.9 pg/mL to 3.5 pg/mL, 3.4 pg/mL to 3.8 pg/mL, 3.7 pg/mL to 3.9pg/mL, 3.85 pg/mL to 5.0 pg/mL, less than 5.0 pg/mL, less than 0.05ng/mL, less than 0.15 ng/mL, less than 0.2 ng/mL, less than 0.3 ng/mL,less than 0.5 ng/mL, less than 0.7 ng/mL, less than 0.75 ng/mL, lessthan 0.9 ng/mL, less than 1.0 ng/mL, less than 1.1 ng/mL, less than 1.5ng/mL, less than 1.75 ng/mL, less than 2.0 ng/mL, less than 2.25 ng/mL,less than 5.0 ng/mL, less than 6.0 ng/mL, less than 7.0 ng/mL, less than10.0 ng/mL, or less than 100.0 ng/mL. The threshold for determining adecrease of the level of IHH in biological fluids can vary, for example,IHH can be or about: 0 pg/mL, greater than 0 pg/mL to 0.1 pg/mL, 0.05pg/mL to 0.15 pg/mL, 0.125 pg/mL to 0.2 pg/mL, 0.15 pg/mL to 0.30 pg/mL,0.25 pg/mL to 0.5 pg/mL, 0.4 pg/mL to 0.7 pg/mL, 0.6 pg/mL to 0.75pg/mL, 0.725 pg/mL to 0.9 pg/mL, 0.8 pg/mL to 1.0 pg/mL, less than 1.0pg/mL, less than 2.0 pg/mL, less than 5.0 pg/mL, less than 10.0 pg/mL,less than 0.05 ng/mL, less than 0.15 ng/mL, less than 0.2 ng/mL, lessthan 0.3 ng/mL, less than 0.5 ng/mL, less than 0.7 ng/mL, less than 0.75ng/mL, less than 0.9 ng/mL, less than 1.0 ng/mL, less than 1.1 ng/mL,less than 1.5 ng/mL, less than 1.75 ng/mL, less than 2.0 ng/mL, lessthan 2.25 ng/mL, less than 5.0 ng/mL, less than 6.0 ng/mL, less than 7.0ng/mL, less than 10.0 ng/mL, or less than 100.0 ng/mL.

The present disclosure can also provide for the measurement of levels ofone or more biological substances associated with loss and/or distortionof taste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia,hypogeusia, dysgeusia, phantogeusia, and/or ageusia. The level of thesebiological substances can include but are not limited to IL-1α, IL-1β,IL-1ra, IL-1 RII, IL-1α, IL-1β, IL-1ra, IL-1 RII, IL-2, IL-2R, IL-6,IL-10, IL-18, TNF-α, IFN-β, IFN-γ, cytokines, IgE, or eosinophils.

For example, molecules such as IL-1α, IL-1β, IL-1ra, IL-1 RII, IL-1α,IL-1β, IL-1ra, IL-1 RII, IL-2, IL-2R, IL-6, IL-10, IL-18, TNF-α, IFN-β,IFN-γ, or any combination thereof can be elevated. In some cases themolecule can be IL-6. In some cases the threshold for determiningelevation about 15 pg/mL to about 45 pg/mL and wherein higher levels ofthe molecules described herein may indicate that the subject hashyposmia. The threshold can be 0.1, 0.2. 0.3, 0.4, 0.5, 0.6, 0.7, 0.8,0.9, 1, 2, 3, 4, 5, 10, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43,44, 45, 50, 60, 70 80, 90 or 100 pg/mL. The level of IL-6 wherein thethreshold level of IL-6 can be from or from about: 0.05 pg/mL to 50pg/mL and about 0.05 pg/mL to about 50 pg/mL, for example, 0.05 pg/mL to0.1 pg/mL, or 0.75 pg/mL to 0.125 pg/mL, or 0.1 pg/mL to 0.2 pg/mL, or0.15 pg/mL to 0.3 pg/mL, or 0.2 pg/mL to 0.4 pg/mL, or 0.3 pg/mL to 0.5pg/mL, or 0.4 pg/mL to 0.6 pg/mL, or 0.5 pg/mL to 0.7 pg/mL, or 0.6pg/mL to 0.8 pg/mL, or 0.7 pg/mL to 0.9 pg/mL, or 0.8 pg/mL to 1.0pg/mL, or 0.5 pg/mL to 2.0 pg/mL, or 1.5 pg/mL to 3.0 pg/mL, or 2.5pg/mL to 4.0 pg/mL, or 3.5 pg/mL to 5.0 pg/mL, or 4 pg/mL to 6 pg/mL, or5 pg/mL to 7 pg/mL, or 6 pg/mL to 8 pg/mL, or 7 pg/mL to 9 pg/mL, or 8pg/mL to 10 pg/mL, or 9 pg/mL to 11 pg/mL, or 10 pg/mL to 12 pg/mL, or11 pg/mL to 13 pg/mL, or 11 pg/mL to 13 pg/mL, or 12 pg/mL to 16 pg/mL,or 15 pg/mL to 25 pg/mL, or 20 pg/mL to 40 pg/mL, or 30 pg/mL to 50pg/mL, or 40 pg/mL to 60 pg/mL, or 50 pg/mL to 70 pg/mL, or 60 pg/mL to80 pg/mL, or 70 pg/mL to 90 pg/mL, or 80 pg/mL to 100 pg/mL. By way ofexample only, and not to be construed as limiting in any way, the rangefor IHH in salvia, urine, and plasma, can be or about: 0.05 pg/mL to 0.1pg/mL, or 0.75 pg/mL to 0.125 pg/mL, or 0.1 pg/mL to 0.2 pg/mL, or 0.15pg/mL to 0.3 pg/mL, or 0.2 pg/mL to 0.4 pg/mL, or 0.3 pg/mL to 0.5pg/mL, or 0.4 pg/mL to 0.6 pg/mL, or 0.5 pg/mL to 0.7 pg/mL, or 0.6pg/mL to 0.8 pg/mL, or 0.7 pg/mL to 0.9 pg/mL, or 0.8 pg/mL to 1.0pg/mL, or 0.5 pg/mL to 2.0 pg/mL, or 1.5 pg/mL to 3.0 pg/mL, or 2.5pg/mL to 4.0 pg/mL, or 3.5 pg/mL to 5.0 pg/mL, or 4 pg/mL to 6 pg/mL;and in mucus, can be or about 0.5 pg/mL to 2.0 pg/mL, or 1.5 pg/mL to3.0 pg/mL, or 2.5 pg/mL to 4.0 pg/mL, or 3.5 pg/mL to 5.0 pg/mL, or 4pg/mL to 6 pg/mL, or 5 pg/mL to 7 pg/mL, or 6 pg/mL to 8 pg/mL, or 7pg/mL to 9 pg/mL, or 8 pg/mL to 10 pg/mL, or 9 pg/mL to 11 pg/mL, or 10pg/mL to 12 pg/mL, or 11 pg/mL to 13 pg/mL, or 11 pg/mL to 13 pg/mL, or12 pg/mL to 16 pg/mL, or 15 pg/mL to 25 pg/mL, or 20 pg/mL to 40 pg/mL,or 30 pg/mL to 50 pg/mL, or 40 pg/mL to 60 pg/mL, or 50 pg/mL to 70pg/mL, or 60 pg/mL to 80 pg/mL, or 70 pg/mL to 90 pg/mL, or 80 pg/mL to100 pg/mL, less than 0.05 ng/mL, less than 0.15 ng/mL, less than 0.2ng/mL, less than 0.3 ng/mL, less than 0.5 ng/mL, less than 0.7 ng/mL,less than 0.75 ng/mL, less than 0.9 ng/mL, less than 1.0 ng/mL, lessthan 1.1 ng/mL, less than 1.5 ng/mL, less than 1.75 ng/mL, less than 2.0ng/mL, less than 2.25 ng/mL, less than 5.0 ng/mL, less than 6.0 ng/mL,less than 7.0 ng/mL, less than 10.0 ng/mL, or less than 100.0 ng/mL.

Measurements or testing of one or more biological substances can becompared to thresholds or can be compared to level or amounts of otherbiological substances.

For example, elevated levels of IgE in biological samples can be used inaiding the diagnosis of loss and/or distortion of taste or smell, e.g.,hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia. The threshold level can be 75 kU/L. Thethreshold may also be 75 kU/L-125 kU/L. The threshold may also be 45,55, 65, 75, 76, 77, 78, 79, 80, 85, 90, 95, 100, 105, 110, 115, 120,125, 150, 175, 200 kU/L. The threshold may also be higher than 75 kU/L,100 kU/L, or 125 kU/L and about 75 kU/L, about 100 kU/L, or about 125kU/L. Elevated levels of IgE can be elevated above a threshold value.Elevated levels may indicate that a subject has a loss and/or distortionof taste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia,hypogeusia, dysgeusia, phantogeusia, and/or ageusia. A subject may haveloss and/or distortion of taste or smell, e.g., hyposmia, dysosmia,anosmia, phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusiaif the subject's IgE values are measured above 45, 55, 65, 75, 76, 77,78, 79, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 150, 175, 200kU/L. A subject may have loss and/or distortion of taste or smell, e.g.,hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia if the subject's IgE values are measuredabove 75 kU/L, 100 kU/L, or 125 kU/L and about 75 kU/L, about 100 kU/L,or about 125 kU/L. A subject's IgE value can be determined by anysuitable assay as described herein. For example, the level of IgE can bemeasured using a fluorescence polarization assay.

Elevated levels of eosinophils in biological samples, e.g., bloodsamples, can be used in aiding the diagnosis of hyposmia. The thresholdlevel can be 200 cells/HPF. The threshold may also be 200 cells/HPF-400cells/HPF. The threshold may also be 50-600 cells/HPF. The threshold mayalso be 50, 100, 200, 210, 220, 230, 240, 250, 260, 270, 280, 290, 300,310, 320, 330, 340, 350, 360, 370, 380, 390 or 400, 420, 440, 460, 480,500, 520, 540, 560, 580 or 600 cells/HPF. The threshold may also be 300cells/HPF (high powered field), 350 cells/HPF, or 400 cells/HPF andabout 300 cells/HPF, 350 cells/HPF, or 400 cells/HPF. Elevated level ofeosinophils can be elevated about a threshold value. Elevated levels mayindicate that a subject has a hyposmia. A subject may have hyposmia ifthe subject's eosinophils count or levels is above 50, 100, 200, 210,220, 230, 240, 250, 260, 270, 280, 290, 300, 310, 320, 330, 340, 350,360, 370, 380, 390 or 400, 420, 440, 460, 480, 500, 520, 540, 560, 580or 600 cells/HPF. A subject may have hyposmia if the subject'seosinophils count or levels is above 300 cells/HPF (high powered field),350 cells/HPF, or 400 cells/HPF and about 300 cells/HPF, 350 cells/HPF,or 400 cells/HPF. A subject' eosinophils count can be determined by anysuitable assay as described herein, including, but not limited to,microscopy or Coulter counter.

FIG. 12 illustrates an exemplary practice of the diagnostic methodsdisclosed herein. A sample is collected from a subject, as illustratedby a syringe representing an means disclosed herein for the collectionof a biological sample. The method of collecting the biological samplewill depend upon the type of biological sample collected. The biologicalsample can be analyzed to measure a level of one or more biomarkers fromthe biological sample using a microscope, or any other means to measurethe biomarker level. The levels for each of the one or more biomarkerscan be used in a computer implemented diagnosis. The resulting diagnosisbased on the biomarker analysis can be sent to a party via acommunication media, represented by the computer, diagonal pointingarrow, and printer. Based on the results of the diagnosis, the patientcan be treated for a taste or smell disorder.

Methods for Diagnosis, Evaluation, and/or Treatment

The Hedgehog signaling pathway is known to be a key regulator of animaldevelopment, particularly during late stages of embryogenesis andmetamorphosis. Mammals are have three Members of the hedgehog signalingpathway, Sonic Hedgehog (SHH), Desert Hedgehog (DHH), and Indianhedgehog (IHH). The pathway is implicated in the development of somecancers. However, the role of members of the hedgehog signaling pathwayin diagnosing and treating loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia, has yet to be determined.

In one aspect, disclosed herein are methods of diagnosing loss and/ordistortion of taste or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia in asubject, the methods comprising (a) obtaining one or more biologicalsamples from the subject; (b) measuring a level of one or more membersof the hedgehog signaling pathway in one or more biological samples fromthe subject; and (c) diagnosing the subject with loss and/or distortionof taste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia,hypogeusia, dysgeusia, phantogeusia, and/or ageusia based upon the levelof one or more members of the hedgehog signaling pathway that can belower than a threshold level. Disclosed herein are also methods ofevaluating the improvement in, decline in, and/or no change in tasteand/or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia,dysgeusia, phantogeusia, and/or ageusia in a subject, the methodscomprising (a) treating the subject with one or more drugs; (b)obtaining one or more biological samples from the subject; (c) measuringa level of one or more members of the hedgehog signaling pathway in oneor more biological samples from the subject; and (d) diagnosing thesubject with an improvement in, decline in, no change in, diminution inand/or distortion, taste and/or smell, e.g., hyposmia, dysosmia,anosmia, phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusiabased upon the level of one or more members of the hedgehog signalingpathway that can be above, lower, and/or the same, than a thresholdlevel. The threshold level can be an average level for the one or moremembers of the hedgehog signaling pathway as measured in a controlpopulation comprising subjects with normal olfactory and/or tastefunction. The level of one or more members of the hedgehog signalingpathway can be at least one order of magnitude lower than said thresholdlevel. For example, 2, 3, 4, 5, 10, 15, 16, 17, 18, 19, 20, 21, 22, 23,24, 25, 26, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40,41, 42, 43, 44, 45, 50, 60, 70 80, 90, 100, 150, 200, 250, 300, 400,500, 600, 700, 800, 900, or 1000 or more orders of magnitude lower thansaid threshold level. The methods of this invention can further compriseat least one of: (a) treating the subject diagnosed with loss and/ordistortion of taste or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia; (b)transferring the diagnosed result via a communication medium; and (c)computer implementing the diagnosis.

Some patients can be diagnosed with loss and/or distortion of taste orsmell, e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia,dysgeusia, phantogeusia, and/or ageusia without comparing the levels ofmembers of the hedgehog signaling pathway to a threshold number.Disclosed herein are methods of diagnosing loss and/or distortion oftaste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia,hypogeusia, dysgeusia, phantogeusia, and/or ageusia in a subject, themethods comprising obtaining one or more biological samples from thesubject; measuring a level of one or more members of the hedgehogsignaling pathway in one or more biological samples from the subject;and diagnosing the subject with loss and/or distortion of taste orsmell, e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia,dysgeusia, phantogeusia, and/or ageusia based on one or more of: (i) thelevel of Sonic Hedgehog (SHH) that is or about greater than 0 pg/mL to8,500 pg/mL; (ii) the level of Indian hedgehog (IHH) that is or aboutgreater than 0 pg/mL to 1.0 pg/mL; and (iii) the level of DesertHedgehog (DHH) that is or about greater than 0 pg/mL to 5.0 pg/mL.

In order to evaluative the improvement in, decline in, and/or no changeof patients (e.g., patient response) to drugs, e.g., theophylline (e.g.,nasal and/or oral), cGMP activators (e.g., riociguat), and/or cAMPactivators (e.g., forskolin), any drug described in herein, and anycombination thereof, the inventor has developed appropriate methods. Forexample, a patients' response to drugs can be determined by methods ofevaluating the improvement in, decline in, and/or no change in tasteand/or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia,dysgeusia, phantogeusia, and/or ageusia in a subject, the methodscomprising (a) treating the subject with one or more drugs; (b)obtaining one or more biological samples from the subject; (c) measuringa level of one or more members of the hedgehog signaling pathway in oneor more biological samples from the subject; and (d) diagnosing thesubject with an improvement in, decline in, no change in, diminution inand/or distortion, taste and/or smell, e.g., hyposmia, dysosmia,anosmia, phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusiabased upon the level of one or more members of the hedgehog signalingpathway that can be above, lower, and/or the same, than a thresholdlevel. For instance, if a subject does not responds to drugs, the methodof (a) treating the subject with one or more drugs; (b) obtaining one ormore biological samples from the subject; and (c) measuring a level ofone or more members of the hedgehog signaling pathway in one or morebiological samples from the subject; can lead to (d) diagnosing thesubject with no change in taste and/or smell, e.g., hyposmia, dysosmia,anosmia, phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusiabased upon the level of one or more members of the hedgehog signalingpathway that can be the same or about the same as a threshold level. Inanother example, if the subject responds negatively to drug treatment,the method of (a) treating the subject with one or more drugs, (b)obtaining one or more biological samples from the subject; and (c)measuring a level of one or more members of the hedgehog signalingpathway in one or more biological samples from the subject; can lead to(d) diagnosing the subject with decrease in taste and/or smell, e.g.,hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia based upon the level of one or more membersof the hedgehog signaling pathway that can be lower than a thresholdlevel. In further example, if the subject responds positively to drugtreatment, the method of (a) treating the subject with one or moredrugs; (b) obtaining one or more biological samples from the subject;and (c) measuring a level of one or more members of the hedgehogsignaling pathway in one or more biological samples from the subject;can lead to (d) diagnosing the subject with increase in taste and/orsmell, e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia,dysgeusia, phantogeusia, and/or ageusia based upon the level of one ormore members of the hedgehog signaling pathway that can be higher than athreshold level. In some embodiments, (b) and (c) are performed beforeand/or after (a). For example, the methods described herein can compriseevaluating the improvement in, decline in, and/or no change in tasteand/or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia,dysgeusia, phantogeusia, and/or ageusia in a subject, the methodscomprising (a) obtaining one or more biological samples from thesubject; (b) measuring a level of one or more members of the hedgehogsignaling pathway in one or more biological samples from the subject;(c) treating the subject with one or more drugs; (d) obtaining one ormore biological samples from the subject; (e) measuring a level of oneor more members of the hedgehog signaling pathway in one or morebiological samples from the subject; and (f) diagnosing the subject withan improvement in, decline in, no change in, diminution in and/ordistortion, taste and/or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia basedupon the level of one or more members of the hedgehog signaling pathwaythat can be above, lower, and/or the same, than a threshold level. Inanother example, the methods described herein can comprise evaluatingthe improvement in, decline in, and/or no change in taste and/or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia in a subject, the methods comprising (a)obtaining one or more biological samples from the subject; (b) measuringa level of one or more members of the hedgehog signaling pathway in oneor more biological samples from the subject; (c) treating the subjectwith one or more drugs; and (d) diagnosing the subject with animprovement in, decline in, no change in, diminution in and/ordistortion, taste and/or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia basedupon the level of one or more members of the hedgehog signaling pathwaythat can be above, lower, and/or the same, than a threshold level.Without being bound by theory, in many instances, taste and smellfunction can improve simultaneously, however, in some instances, tastefunction may improve when smell function declines, and smell functionmay improve when taste function declines. In additional embodiments, themethod can further comprise one or more of the following: (a) patientsdescribed herein can be treated with more drugs (e.g., increase indosage), can be treated with less drugs (e.g., decrease in dosage),maintained on the same drug (e.g., same dosage), switched to a differentdrug (e.g., from a PDE inhibitor to a cGMP activator), and/orcombinations thereof; (b) the measuring a level of one or more membersof the hedgehog signaling pathway can be performed by an antibody-basedassay, for example, ELISA; (c) the diagnosis can be computerimplemented; and (d) any combination thereof.

In order to effectively measure levels of members of the hedgehogsignaling pathway in subjects, one or more biological samples can beneeded. As described in detail above, various methods for retrieving andpreparing biological samples are known and can be used to extract andprepare biological samples for testing. Also as described above, the oneor more biological samples can comprise one or more bodily fluids. Theone or more bodily fluids can also comprise a whole blood sample, aserum sample, a plasma sample, a urine sample, a saliva sample, a mucussample, a perspiration sample, or any combination thereof. If a singlebodily fluid is used, the one or more bodily fluids can also comprise amucus sample (e.g., a nasal mucus sample), a plasma sample, a serumsample, a whole blood sample, and/or a perspiration sample.

The one or more members of the hedgehog signaling pathway can beselected from a group consisting of: Sonic Hedgehog (SHH), DesertHedgehog (DHH), and/or Indian hedgehog (IHH). The one or more members ofthe hedgehog signaling pathway can be SHH, DHH, IHH, or any combinationthereof. Although a mammalian (e.g., human) hedgehog can be measured, itis also contemplated that a non-mammalian hedgehog can be measured.

The measuring of the level of members of the hedgehog signaling pathwaycan be performed by using methods in the art. Methods incorporating theuse of antibodies can be particularly useful. However, this is not to beconstrued as limiting the methods of measuring based on antibody tests.The measuring of the level of one or more members of the hedgehogsignaling pathway can comprise using one or more antibodies that bindone or more members of the hedgehog signaling pathway. The measuring canfurther comprise one or more antibodies that bind one or more members ofthe hedgehog signaling pathway wherein the one or more antibodies areused in an immunostain, an immunoprecipitation, animmunoelectrophoresis, an immunoblot, a western blot, or aspectrophotometry assay. It is contemplated that the methods can alsofurther comprise one or more antibodies that bind one or more members ofthe hedgehog signaling pathway wherein the one or more antibodies areused in the spectrophotometry assay that can be an EMIT (EnzymeMultiplied Immunoassay Technique) assay or an ELISA (Enzyme LinkedImmunosorbent Assay). Some examples of measuring techniques aredescribed throughout the specification. For example, the methods cancomprise using one or more techniques that are fluorescence microscopy,a radioimmunoassay, a fluorescence immunoassay, mass spectrometry,liquid chromatography, electrophoresis, or any combination thereof.

To assess if a subject has loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia, based on levels of one or more members ofthe hedgehog signaling pathway, a threshold comparison, e.g., a basallevel can be used. Thus, the threshold level can be an average level forone or more members of the hedgehog signaling pathway as measured in acontrol population comprising subjects with normal olfactory and/orgustatory function. The level of one or more members of the hedgehogsignaling pathway can be at least one order of magnitude lower than saidthreshold level. For example, 2, 3, 4, 5, 10, 15, 16, 17, 18, 19, 20,21, 22, 23, 24, 25, 26, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37,38, 39, 40, 41, 42, 43, 44, 45, 50, 60, 70 80, 90, 100, 150, 200, 250,300, 400, 500, 600, 700, 800, 900, or 1000 or more orders of magnitudelower than said threshold level.

Levels of pro-inflammatory cytokines, in combination or individuallywith members of the hedgehog signaling pathway levels and/or otherbiological markers, can be helpful in diagnosing a subject with lossand/or distortion of taste or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia. Forexample, some methods can further comprise measuring a level of one ormore pro-inflammatory cytokines in at least one or more of thebiological samples. The methods can also comprise measuring a level ofone or more pro-inflammatory cytokines selected from a group consistingof: IL-1α, IL-1β, IL-6, IL-18, TNF-α, or any combination thereof.Alternatively, the methods can also comprise measuring a level of one ormore pro-inflammatory cytokines wherein the one or more pro-inflammatorycytokines can comprise IL-6. The methods can also comprise measuring thelevel of IL-6 wherein the threshold level of IL-6 can be 0.1, 0.2. 0.3,0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1, 2, 3, 4, 5, 10, 15, 16, 17, 18, 19, 20,21, 22, 23, 24, 25, 26, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37,38, 39, 40, 41, 42, 43, 44, 45, 50, 60, 70 80, 90 or 100 pg/mL. Thelevel of IL-6 wherein the threshold level of IL-6 can be from or fromabout: 0.05 pg/mL to 50 pg/mL and about 0.05 pg/mL to about 50 pg/mL,for example, 0.05 pg/mL to 0.1 pg/mL, or 0.75 pg/mL to 0.125 pg/mL, or0.1 pg/mL to 0.2 pg/mL, or 0.15 pg/mL to 0.3 pg/mL, or 0.2 pg/mL to 0.4pg/mL, or 0.3 pg/mL to 0.5 pg/mL, or 0.4 pg/mL to 0.6 pg/mL, or 0.5pg/mL to 0.7 pg/mL, or 0.6 pg/mL to 0.8 pg/mL, or 0.7 pg/mL to 0.9pg/mL, or 0.8 pg/mL to 1.0 pg/mL, or 0.5 pg/mL to 2.0 pg/mL, or 1.5pg/mL to 3.0 pg/mL, or 2.5 pg/mL to 4.0 pg/mL, or 3.5 pg/mL to 5.0pg/mL, or 4 pg/mL to 6 pg/mL, or 5 pg/mL to 7 pg/mL, or 6 pg/mL to 8pg/mL, or 7 pg/mL to 9 pg/mL, or 8 pg/mL to 10 pg/mL, or 9 pg/mL to 11pg/mL, or 10 pg/mL to 12 pg/mL, or 11 pg/mL to 13 pg/mL, or 11 pg/mL to13 pg/mL, or 12 pg/mL to 16 pg/mL, or 15 pg/mL to 25 pg/mL, or 20 pg/mLto 40 pg/mL, or 30 pg/mL to 50 pg/mL, or 40 pg/mL to 60 pg/mL, or 50pg/mL to 70 pg/mL, or 60 pg/mL to 80 pg/mL, or 70 pg/mL to 90 pg/mL, or80 pg/mL to 100 pg/mL. By way of example only, and not to be construedas limiting in any way, the range for IL-6 in salvia, urine, and plasma,can be or about: 0.05 pg/mL to 0.1 pg/mL, or 0.75 pg/mL to 0.125 pg/mL,or 0.1 pg/mL to 0.2 pg/mL, or 0.15 pg/mL to 0.3 pg/mL, or 0.2 pg/mL to0.4 pg/mL, or 0.3 pg/mL to 0.5 pg/mL, or 0.4 pg/mL to 0.6 pg/mL, or 0.5pg/mL to 0.7 pg/mL, or 0.6 pg/mL to 0.8 pg/mL, or 0.7 pg/mL to 0.9pg/mL, or 0.8 pg/mL to 1.0 pg/mL, or 0.5 pg/mL to 2.0 pg/mL, or 1.5pg/mL to 3.0 pg/mL, or 2.5 pg/mL to 4.0 pg/mL, or 3.5 pg/mL to 5.0pg/mL, or 4 pg/mL to 6 pg/mL; and in mucus, can be or about 0.5 pg/mL to2.0 pg/mL, or 1.5 pg/mL to 3.0 pg/mL, or 2.5 pg/mL to 4.0 pg/mL, or 3.5pg/mL to 5.0 pg/mL, or 4 pg/mL to 6 pg/mL, or 5 pg/mL to 7 pg/mL, or 6pg/mL to 8 pg/mL, or 7 pg/mL to 9 pg/mL, or 8 pg/mL to 10 pg/mL, or 9pg/mL to 11 pg/mL, or 10 pg/mL to 12 pg/mL, or 11 pg/mL to 13 pg/mL, or11 pg/mL to 13 pg/mL, or 12 pg/mL to 16 pg/mL, or 15 pg/mL to 25 pg/mL,or 20 pg/mL to 40 pg/mL, or 30 pg/mL to 50 pg/mL, or 40 pg/mL to 60pg/mL, or 50 pg/mL to 70 pg/mL, or 60 pg/mL to 80 pg/mL, or 70 pg/mL to90 pg/mL, or 80 pg/mL to 100 pg/mL.

To assess if a subject has loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia, based on levels of one or morepro-inflammatory cytokines, a threshold comparison, e.g., a basal level,can be used. For example, the methods can further comprise measuring alevel of one or more pro-inflammatory cytokines wherein diagnosing canbe further based upon the level of at least one of the one or morepro-inflammatory cytokines being higher than an average pro-inflammatorycytokine level as measured in the control population comprising subjectswith normal olfactory and/or gustatory function.

Levels of anti-inflammatory cytokines, in combination or individuallywith members of the hedgehog signaling pathway levels and/or otherbiological markers, can be helpful in diagnosing a subject with lossand/or distortion of taste or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia. Forexample, the methods can further comprise measuring a level of one ormore anti-inflammatory cytokines in at least one of the biologicalsamples. The methods can also comprise measuring a level of one or moreanti-inflammatory cytokines wherein the one or more anti-inflammatorycytokines can be selected from a group consisting of: IL-1ra, IL-10,IFN-γ, IFN-β, or combinations thereof.

To assess if a subject has loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia, based on levels of one or moreanti-inflammatory cytokines, a threshold comparison, e.g., a basallevel, can be used. For example, the diagnosing can be further basedupon the level of at least one of the one or more anti-inflammatorycytokines being lower than an average anti-inflammatory cytokine levelas can be measured in the control population comprising subjects withnormal olfactory and/or gustatory function.

Levels of other biological makers, in combination or individually withmembers of the hedgehog signaling pathway levels and/or other biologicalmarkers, can be helpful in diagnosing a subject with loss and/ordistortion of taste or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia. Forexample, the methods can further comprise measuring a level ofimmunoglobulin E (IgE), eosinophils, cyclic adenosine monophosphate(cAMP), cyclic guanosine monophosphate (cGMP), nitric oxide (NO), IL-1RII, IL-2R, or any combination thereof in at least one of the one ormore biological samples.

To assess if a subject has loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia, based on the level of IgE, a thresholdcomparison, e.g., a basal level, can be used. Thus, the methods canfurther comprise measuring the level of IgE, wherein diagnosing can befurther based upon the level of IgE being higher than an average IgElevel as measured in the control population comprising subjects withnormal olfactory and/or gustatory function. The methods can furthercomprise measuring the level of IgE, wherein diagnosing can be furtherbased upon the level of IgE being higher than 75 kU/L, 100 kU/L, or 125kU/L and about 75 kU/L, about 100 kU/L, or about 125 kU/L. The methodscan further comprise measuring the level of IgE, wherein measuring thelevel of IgE can comprise a fluorescence polarization assay.

To assess if a subject has loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia, based on the level of eosinophils, athreshold comparison, e.g., a basal level, can be used. The methods canfurther comprise measuring the level of eosinophils, wherein diagnosingcan be further based upon the level of eosinophils being higher than anaverage eosinophils level as measured in the control populationcomprising subjects with normal olfactory and/or gustatory function. Themethods can further comprise the measuring the level of eosinophils,wherein diagnosing can be further based upon the level of eosinophilsbeing higher than 300 cells/HPF (high powered field), 350 cells/HPF, or400 cells/HPF and about 300 cells/HPF, 350 cells/HPF, or 400 cells/HPF.The measuring the level of eosinophils can be performed with a Coultercounter.

To assess if a subject has loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia, based on the level of NO, a thresholdcomparison, e.g., a basal level, can be used. The methods can furthercomprise measuring the level of NO, wherein diagnosing can be furtherbased upon the level of NO being lower than an average NO level asmeasured in the control population comprising subjects with normalolfactory and/or gustatory function.

To assess if a subject has loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia, based on the level of cAMP, a thresholdcomparison, e.g., a basal level, can be used. The methods can furthercomprise measuring the level of cAMP, wherein diagnosing can be furtherbased upon the level of cAMP being lower than an average cAMP level asmeasured in the control population comprising subjects with normalolfactory and/or gustatory function.

To assess if a subject has loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia, based on the level of cGMP, a thresholdcomparison, e.g., a basal level, can be used. The methods can furthercomprise measuring the level of cGMP, wherein diagnosing can be furtherbased upon the level of cGMP being lower than an average cGMP level asmeasured in the control population comprising subjects with normalolfactory and/or gustatory function.

The inventors have found that decreased levels of members of thehedgehog signaling pathway can be used to diagnose and recommendtreating subjects with loss and/or distortion of taste or smell, e.g.,hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia. For example, the subject can be diagnosedwith loss and/or distortion of taste or smell, e.g., hyposmia, dysosmia,anosmia, phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusiabased on one or more of: (a) the level of SHH that can be or about: 0pg/mL, greater than 0 pg/mL to less than less than 1 pg/mL, 1 pg/mL to25 pg/mL, 15 pg/mL to 30 pg/mL, 20 pg/mL to 40 pg/mL; 35 pg/mL to 50pg/mL; 45 pg/mL to 100 pg/mL; 75 pg/mL to 150 pg/mL, 125 pg/mL to 1000pg/mL, 900 pg/mL to 2500 pg/mL, 2000 pg/mL to 5000 pg/mL, 4000 pg/mL to7500 pg/mL, 6000 pg/mL to 10,000 pg/mL; (b) the level of IHH that can beor about: 0 pg/mL, greater than 0 pg/mL to 0.1 pg/mL, 0.05 pg/mL to 0.15pg/mL, 0.125 pg/mL to 0.2 pg/mL, 0.15 pg/mL to 0.30 pg/mL, 0.25 pg/mL to0.5 pg/mL, 0.4 pg/mL to 0.7 pg/mL, 0.6 pg/mL to 0.75 pg/mL, 0.725 pg/mLto 0.9 pg/mL, 0.8 pg/mL to 1.0 pg/mL, less than 1.0 pg/mL, less than0.05 ng/mL, less than 0.15 ng/mL, less than 0.2 ng/mL, less than 0.3ng/mL, less than 0.5 ng/mL, less than 0.7 ng/mL, less than 0.75 ng/mL,less than 0.9 ng/mL, less than 1.0 ng/mL, less than 1.1 ng/mL, less than1.5 ng/mL, less than 1.75 ng/mL, less than 2.0 ng/mL, less than 2.25ng/mL, less than 5.0 ng/mL, less than 6.0 ng/mL, less than 7.0 ng/mL,less than 10.0 ng/mL, or less than 100.0 ng/mL; (c) the level of DHHthat can be or about: 0 pg/mL, greater than 0 pg/mL to 0.1 pg/mL, 0.05pg/mL to 0.15 pg/mL, 0.125 pg/mL to 0.2 pg/mL, 0.15 pg/mL to 0.30 pg/mL,0.25 pg/mL to 0.5 pg/mL, 0.4 pg/mL to 0.7 pg/mL, 0.6 pg/mL to 0.75pg/mL, 0.725 pg/mL to 0.9 pg/mL, 0.8 pg/mL to 1.0 pg/mL, 0.9 pg/mL to1.1 pg/mL, 1.0 pg/mL to 1.3 pg/mL, 1.2 pg/mL to 1.5 pg/mL, 1.4 pg/mL to2.0 pg/mL, 1.9 pg/mL to 2.5 pg/mL, 2.4 pg/mL to 3.0 pg/mL, 2.9 pg/mL to3.5 pg/mL, 3.4 pg/mL to 3.8 pg/mL, 3.7 pg/mL to 3.9 pg/mL, 3.85 pg/mL to5.0 pg/mL, less than 5.0 pg/mL, less than 0.05 ng/mL, less than 0.15ng/mL, less than 0.2 ng/mL, less than 0.3 ng/mL, less than 0.5 ng/mL,less than 0.7 ng/mL, less than 0.75 ng/mL, less than 0.9 ng/mL, lessthan 1.0 ng/mL, less than 1.1 ng/mL, less than 1.5 ng/mL, less than 1.75ng/mL, less than 2.0 ng/mL, less than 2.25 ng/mL, less than 5.0 ng/mL,less than 6.0 ng/mL, less than 7.0 ng/mL, less than 10.0 ng/mL, or lessthan 100.0 ng/mL.

The inventors have also found that measuring the level of particularbiological markers can, for example, be used to diagnose and treatsubjects with loss and/or distortion of taste or smell, e.g., hyposmia,dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia, phantogeusia,and/or ageusia. The methods can further comprise diagnosing the subjectwith loss and/or distortion of taste or smell, e.g., hyposmia, dysosmia,anosmia, phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusiacan be based upon one or more measurements: (a) the level of IL-1α thatcan be or about: 125 pg/mL to 195 pg/mL, 150 pg/mL to 170 pg/mL, 120pg/mL to 170 pg/mL, or 150 pg/mL to 195 pg/mL, or 185 pg/mL to 500 pg/mL(e.g., by way of example only, in nasal mucus from about: 15 pg/mL to 30pg/mL, or 25 pg/mL to 50 pg/mL, or 45 pg/mL to 75 pg/mL, or 70 pg/mL to100 pg/mL, or 90 pg/mL to 150 pg/mL, or 125 pg/mL to 200 pg/mL, or 150pg/mL to 250 pg/mL, or from 200 pg/mL to 300 pg/mL, or from 250 pg/mL to350 pg/mL, or 300 pg/mL to 400 pg/mL, or 350 pg/mL to 450 pg/mL, or 400pg/mL to 500 pg/mL; and in saliva from 0.1 pg/mL to 0.5 pg/mL, or 0.25pg/mL to 0.75 pg/mL, or 0.6 pg/mL to 0.9 pg/mL, or 0.7 pg/mL to 1.0pg/mL, or 0.9 pg/mL to 1.5 pg/mL, or 1.25 pg/mL to 2.0 pg/mL, or 1.75pg/mL to 2.5 pg/mL, or 2.4 pg/mL to 3.0 pg/mL, 2.7 pg/mL to 3.5 pg/mL or3.4 pg/mL to 4.5 pg/mL, or 4.0 pg/mL to 5.0 pg/mL, or 4.6 pg/mL to 5.5pg/mL, or 5.4 pg/mL to 6.0 pg/mL, or 5.9 pg/mL to 6.5 pg/mL, or 6.4pg/mL to 7.0 pg/mL, or 6.9 pg/mL to 7.5 pg/mL, or 7.4 pg/mL to 8.0pg/mL, or 7.9 pg/mL to 8.5 pg/mL, or 8.4 pg/mL to 9.0 pg/mL, or 8.9pg/mL to 9.5 pg/mL, or 9.4 pg/mL to 10.0 pg/mL; (b) the level of IL-1βthat can be or about: 10 pg/mL to 30 pg/mL, 25 pg/mL to 50 pg/mL, 45pg/mL to 100 pg/mL, 90 pg/mL to 150 pg/mL, 140 pg/mL to 200 pg/mL, 195pg/mL to 300 pg/mL, 220 pg/mL to 275 pg/mL, 220 pg/mL to 300 pg/mL, or195 pg/mL to 275 pg/mL, 250 pg/mL to 300 pg/mL, 290 pg/mL to 350 pg/mL,340 pg/mL to 400 pg/mL, 390 pg/mL to 450 pg/mL, 440 pg/mL to 500 pg/mL;(c) the level of IL-1ra that can be or about: 50 pg/mL to 150,000 pg/mL,e.g., 30,000 pg/mL to 90,000 pg/mL, 45,000 pg/mL to 75,000 pg/mL, 45,000pg/mL to 90,000 pg/mL, or 30,000 pg/mL to 75,000 pg/mL (e.g., by way ofexample only, in plasma, from about: 1 pg/mL to 25 pg/mL, 20 pg/mL to 40pg/mL, 30 pg/mL to 60 pg/mL, 50 pg/mL to 100 pg/mL, 75 pg/mL to 150pg/mL, 125 pg/mL to 200 pg/mL, 175 pg/mL to 250 pg/mL, 225 pg/mL to 300pg/mL, 275 pg/mL to 350 pg/mL, 325 pg/mL to 400 pg/mL, 375 pg/mL to 450pg/mL, 425 pg/mL to 500 pg/mL, 475 pg/mL to 550 pg/mL, 525 pg/mL to 600pg/mL, 575 pg/mL to 650 pg/mL, 625 pg/mL to 700 pg/mL; in urine, from:100 pg/mL to 500 pg/mL, 400 pg/mL to 1000 pg/mL, 900 pg/mL to 1500pg/mL, 1400 pg/mL to 2000 pg/mL, 1900 pg/mL to 2500 pg/mL, 2400 pg/mL to3000 pg/mL, 2900 pg/mL to 3500 pg/mL, 3400 pg/mL to 4000 pg/mL, 3900pg/mL to 4500 pg/mL, 4400 pg/mL to 5000 pg/mL, 4900 pg/mL to 5500 pg/mL,5400 pg/mL to 6000 pg/mL, 5900 pg/mL to 6500 pg/mL, 6400 pg/mL to 7000pg/mL, 6900 pg/mL to 7500 pg/mL, 7400 pg/mL to 8000 pg/mL, 7900 pg/mL to8500 pg/mL, 8400 pg/mL to 9000 pg/mL, 8900 pg/mL to 9500 pg/mL, 9400pg/mL to 10,000 pg/mL; in nasal mucus from: 2500 pg/mL to 4000 pg/mL,3500 pg/mL to 6000 pg/mL, 5000 pg/mL to 10,000 pg/mL, 9000 pg/mL to15,000 pg/mL, 14,000 pg/mL to 20,000 pg/mL, 19,000 pg/mL to 25,000pg/mL, 24,000 pg/mL to 30,000 pg/mL, 29,000 pg/mL to 35,000 pg/mL,34,000 pg/mL to 40,000 pg/mL, 39,000 pg/mL to 45,000 pg/mL, 44,000 pg/mLto 50,000 pg/mL, 49,000 pg/mL to 55,000 pg/mL, 54,000 pg/mL to 60,000pg/mL, 59,000 pg/mL to 65,000 pg/mL, 64,000 pg/mL to 70,000 pg/mL,69,000 pg/mL to 75,000 pg/mL, 74,000 pg/mL to 80,000 pg/mL, 79,000 pg/mLto 85,000 pg/mL, 84,000 pg/mL to 90,000 pg/mL, 89,000 pg/mL to 95,000pg/mL, 94,000 pg/mL to 100,000 pg/mL, 104,000 pg/mL to 110,000 pg/mL,109,000 pg/mL to 115,000 pg/mL, 114,000 pg/mL to 120,000 pg/mL, 119,000pg/mL to 120,000 pg/mL, 119,000 pg/mL to 125,000 pg/mL, 124,000 pg/mL to130,000 pg/mL, 129,000 pg/mL to 135,000 pg/mL, 134,000 pg/mL to 140,000pg/mL, 139,000 pg/mL to 145,000 pg/mL, 144,000 pg/mL to 150,000 pg/mL);(d) the level of IL-1R that can be or about: 960 pg/mL to 2600 pg/mL,1370 pg/mL to 2190 pg/mL, 1370 pg/mL to 2600 pg/mL, or 960 pg/mL to 2190pg/mL; (e.g., by way of example only, in saliva, from about: 1 pg/mL to5 pg/mL, 5 pg/mL to 10 pg/mL, 9 pg/mL to 15 pg/mL, 14 pg/mL to 20 pg/mL,or 19 pg/mL to 25 pg/mL, or 24 pg/mL to 30 pg/mL, or 29 pg/mL to 35pg/mL, or 34 pg/mL to 40 pg/mL, or 39 pg/mL to 45 pg/mL, 44 pg/mL to 50pg/mL, or 49 pg/mL to 55 pg/mL, or 54 pg/mL to 60 pg/mL, or 59 pg/mL to65 pg/mL, or 64 pg/mL to 70 pg/mL, or 69 pg/mL to 75 pg/mL, 74 pg/mL to80 pg/mL, or 79 pg/mL to 85 pg/mL, or 84 pg/mL to 90 pg/mL, or 89 pg/mLto 95 pg/mL, or 94 pg/mL to 100 pg/mL, or 99 pg/mL to 105 pg/mL, 104pg/mL to 110 pg/mL, or 109 pg/mL to 105 pg/mL, or 104 pg/mL to 110pg/mL, or 109 pg/mL to 115 pg/mL, or 114 pg/mL to 120 pg/mL, or 119pg/mL to 125 pg/mL, 124 pg/mL to 130 pg/mL, or 129 pg/mL to 135 pg/mL,or 134 pg/mL to 140 pg/mL, or 139 pg/mL to 145 pg/mL, or 144 pg/mL to150 pg/mL, or 149 pg/mL to 200 pg/mL; in urine, from: 25 pg/mL to 75pg/mL, 50 pg/mL to 100 pg/mL, 75 pg/mL to 150 pg/mL, 125 pg/mL to 200pg/mL, 175 pg/mL to 250 pg/mL, 225 pg/mL to 300 pg/mL, 275 pg/mL to 350pg/mL, 325 pg/mL to 400 pg/mL, 375 pg/mL to 450 pg/mL, 425 pg/mL to 500pg/mL, 475 pg/mL to 550 pg/mL, 525 pg/mL to 600 pg/mL, 575 pg/mL to 650pg/mL, 625 pg/mL to 700 pg/, 690 pg/mL to 750 pg/mL, 740 pg/mL to 800pg/mL; in nasal mucus, from: 100 pg/mL to 500 pg/mL, 400 pg/mL to 1000pg/mL, 900 pg/mL to 1500 pg/mL, 1400 pg/mL to 2000 pg/mL, 1900 pg/mL to2500 pg/mL, 2400 pg/mL to 3000 pg/mL, 2900 pg/mL to 3500 pg/mL, 3400pg/mL to 4000 pg/mL, 3900 pg/mL to 4500 pg/mL, 4400 pg/mL to 5000 pg/mL,4900 pg/mL to 5500 pg/mL, 5400 pg/mL to 6000 pg/mL; in plasma, from:5000 pg/mL to 10,000 pg/mL, 9000 pg/mL to 15,000 pg/mL, 14,000 pg/mL to20,000 pg/mL, 19,000 pg/mL to 25,000 pg/mL, 24,000 pg/mL to 30,000pg/mL, 29,000 pg/mL to 35,000 pg/mL, 34,000 pg/mL to 40,000 pg/mL,39,000 pg/mL to 45,000 pg/mL, 44,000 pg/mL to 50,000 pg/mL, 49,000 pg/mLto 55,000 pg/mL, 54,000 pg/mL to 60,000 pg/mL, 59,000 pg/mL to 65,000pg/mL, 64,000 pg/mL to 70,000 pg/mL); (e) the level of IL-2 that can beor about: 0 pg/mL, 0.1 pg/mL, 0.2 pg/mL, 0.3 pg/mL, or 0.5 pg/mL; (f)the level of IL-2R that can be or about: 0 to 200 pg/mL, 50 to 150pg/mL, 0 to 150 pg/mL, or 50 to 200 pg/mL (e.g., by way of example only,in saliva, from 0.1 pg/mL to 0.5 pg/mL, or 0.25 pg/mL to 0.75 pg/mL, or0.6 pg/mL to 0.9 pg/mL, or 0.7 pg/mL to 1.0 pg/mL, or 0.9 pg/mL to 1.5pg/mL, or 1.25 pg/mL to 2.0 pg/mL, or 1.75 pg/mL to 2.5 pg/mL, or 2.4pg/mL to 3.0 pg/mL, 2.7 pg/mL to 3.5 pg/mL or 3.4 pg/mL to 4.5 pg/mL, or4.0 pg/mL to 5.0 pg/mL, or 4.6 pg/mL to 5.5 pg/mL, or 5.4 pg/mL to 6.0pg/mL, or 5.9 pg/mL to 6.5 pg/mL, or 6.4 pg/mL to 7.0 pg/mL, or 6.9pg/mL to 7.5 pg/mL, or 7.4 pg/mL to 8.0 pg/mL, or 7.9 pg/mL to 8.5pg/mL, or 8.4 pg/mL to 9.0 pg/mL, or 8.9 pg/mL to 9.5 pg/mL, or 9.4pg/mL to 10.0 pg/mL, from 9.0 pg/mL to 15.0 pg/mL, or 14.0 pg/mL to 20.0pg/mL, or 19.0 pg/mL to 25.0 pg/mL, or 24.0 pg/mL to 30.0 pg/mL, or 29.0pg/mL to 35.0 pg/mL, or 34.0 pg/mL to 40.0 pg/mL, or 39.0 pg/mL to 45.0pg/mL, or 44.0 pg/mL to 50.0 pg/mL; in nasal mucus from: 0.1 pg/mL to 3pg/mL, 2.5 pg/mL to 4 pg/mL, 3.5 pg/mL to 6 pg/mL, 5 pg/mL to 10 pg/mL,9 pg/mL to 15 pg/mL, 14 pg/mL to 20 pg/mL, or 19 pg/mL to 25 pg/mL, or24 pg/mL to 30 pg/mL, or 29 pg/mL to 35 pg/mL, or 34 pg/mL to 40 pg/mL,or 39 pg/mL to 45 pg/mL, 44 pg/mL to 50 pg/mL, or 49 pg/mL to 55 pg/mL,or 54 pg/mL to 60 pg/mL, or 59 pg/mL to 65 pg/mL, or 64 pg/mL to 70pg/mL, or 69 pg/mL to 75 pg/mL, 74 pg/mL to 80 pg/mL, or 79 pg/mL to 85pg/mL, or 84 pg/mL to 90 pg/mL, or 89 pg/mL to 95 pg/mL, or 94 pg/mL to100 pg/mL, or 99 pg/mL to 105 pg/mL, 104 pg/mL to 110 pg/mL, or 109pg/mL to 105 pg/mL, or 104 pg/mL to 110 pg/mL, or 109 pg/mL to 115pg/mL, or 114 pg/mL to 120 pg/mL, or 119 pg/mL to 125 pg/mL, 124 pg/mLto 130 pg/mL, or 129 pg/mL to 135 pg/mL, or 134 pg/mL to 140 pg/mL, or139 pg/mL to 145 pg/mL, or 144 pg/mL to 150 pg/mL, 149 pg/mL to 200pg/mL, 190 pg/mL to 250 pg/mL, 240 pg/mL to 300 pg/mL, 290 pg/mL to 350pg/mL, 340 pg/mL to 400 pg/mL, 390 pg/mL to 450 pg/mL, 440 pg/mL to 500pg/mL; in urine and plasma from: 50 pg/mL to 100 pg/mL, 75 pg/mL to 150pg/mL, 125 pg/mL to 200 pg/mL, 175 pg/mL to 250 pg/mL, 225 pg/mL to 300pg/mL, 275 pg/mL to 350 pg/mL, 325 pg/mL to 400 pg/mL, 375 pg/mL to 450pg/mL, 425 pg/mL to 500 pg/mL, 475 pg/mL to 550 pg/mL, 525 pg/mL to 600pg/mL, 575 pg/mL to 650 pg/mL, 625 pg/mL to 700 pg/mL, 675 pg/mL to 750pg/mL, 725 pg/mL to 800 pg/mL, 775 pg/mL to 850 pg/mL, 825 pg/mL to 900pg/mL, 875 pg/mL to 950 pg/mL, 925 pg/mL to 1000 pg/mL, 950 pg/mL to1100 pg/mL, 1075 pg/mL to 1200 pg/mL, 1175 pg/mL to 1300 pg/mL, 1275pg/mL to 1400 pg/mL, 1375 pg/mL to 1500 pg/mL; 1475 pg/mL to 1600 pg/mL,1575 pg/mL to 1700 pg/mL, 1675 pg/mL to 1800 pg/mL, 1775 pg/mL to 1900pg/mL, 1875 pg/mL to 2000 pg/mL); (g) the level of IL-6 that can be orabout: 0.1 pg/mL to 2.2 pg/mL, 0.6 pg/mL to 1.7 pg/mL, 0.6 pg/mL to 2.2pg/mL, or 0.1 pg/mL to 1.7 pg/mL (e.g., by way of example only insalvia, urine, and plasma, can be or about: 0.005 pg/mL to 0.01 pg/mL,0.0075 pg/mL to 0.015 pg/mL, 0.0125 pg/mL to 0.02 pg/mL, 0.015 pg/mL to0.03 pg/mL, 0.025 pg/mL to 0.04 pg/mL, 0.035 pg/mL to 0.045 pg/mL, 0.044pg/mL to 0.051 pg/mL, 0.05 pg/mL to 0.1 pg/mL, or 0.75 pg/mL to 0.125pg/mL, or 0.1 pg/mL to 0.2 pg/mL, or 0.15 pg/mL to 0.3 pg/mL, or 0.2pg/mL to 0.4 pg/mL, or 0.3 pg/mL to 0.5 pg/mL, or 0.4 pg/mL to 0.6pg/mL, or 0.5 pg/mL to 0.7 pg/mL, or 0.6 pg/mL to 0.8 pg/mL, or 0.7pg/mL to 0.9 pg/mL, or 0.8 pg/mL to 1.0 pg/mL, or 0.5 pg/mL to 2.0pg/mL, or 1.5 pg/mL to 3.0 pg/mL, or 2.5 pg/mL to 4.0 pg/mL, or 3.5pg/mL to 5.0 pg/mL, or 4 pg/mL to 6 pg/mL; and in nasal mucus, can be orabout 0.05 pg/mL to 0.1 pg/mL, or 0.75 pg/mL to 0.125 pg/mL, or 0.1pg/mL to 0.2 pg/mL, or 0.15 pg/mL to 0.3 pg/mL, or 0.2 pg/mL to 0.4pg/mL, or 0.3 pg/mL to 0.5 pg/mL, or 0.4 pg/mL to 0.6 pg/mL, 0.5 pg/mLto 2.0 pg/mL, or 1.5 pg/mL to 3.0 pg/mL, or 2.5 pg/mL to 4.0 pg/mL, or3.5 pg/mL to 5.0 pg/mL, or 4 pg/mL to 6 pg/mL, or 5 pg/mL to 7 pg/mL, or6 pg/mL to 8 pg/mL, or 7 pg/mL to 9 pg/mL, or 8 pg/mL to 10 pg/mL, or 9pg/mL to 11 pg/mL, or 10 pg/mL to 12 pg/mL, or 11 pg/mL to 13 pg/mL, or11 pg/mL to 13 pg/mL, or 12 pg/mL to 16 pg/mL, or 15 pg/mL to 25 pg/mL,or 20 pg/mL to 40 pg/mL, or 30 pg/mL to 50 pg/mL, or 40 pg/mL to 60pg/mL, or 50 pg/mL to 70 pg/mL, or 60 pg/mL to 80 pg/mL, or 70 pg/mL to90 pg/mL, or 80 pg/mL to 100 pg/mL); (h) the level of IL-10 that can beor about: 0 pg/mL to 3.5 pg/mL, 0.8 pg/mL to 2.7 pg/mL, 0.8 pg/mL to 3.5pg/mL, or 0 pg/mL to 2.7 pg/mL (e.g., by way of example only, in nasalmucus, plasma, and saliva, can be from about: 0.005 pg/mL to 0.01 pg/mL,0.0075 pg/mL to 0.015 pg/mL, 0.0125 pg/mL to 0.02 pg/mL, 0.015 pg/mL to0.03 pg/mL, 0.025 pg/mL to 0.04 pg/mL, 0.035 pg/mL to 0.045 pg/mL, 0.044pg/mL to 0.051 pg/mL, 0.05 pg/mL to 0.1 pg/mL, or 0.75 pg/mL to 0.125pg/mL, 0.05 pg/mL to 0.1 pg/mL, or 0.75 pg/mL to 0.125 pg/mL, or 0.1pg/mL to 0.2 pg/mL, or 0.15 pg/mL to 0.3 pg/mL, or 0.2 pg/mL to 0.4pg/mL, or 0.3 pg/mL to 0.5 pg/mL, or 0.4 pg/mL to 0.6 pg/mL, or 0.5pg/mL to 0.7 pg/mL, or 0.6 pg/mL to 0.8 pg/mL, or 0.7 pg/mL to 0.9pg/mL, or 0.8 pg/mL to 1.0 pg/mL, or 0.5 pg/mL to 2.0 pg/mL, or 1.5pg/mL to 3.0 pg/mL, or 2.5 pg/mL to 4.0 pg/mL, or 3.5 pg/mL to 5.0pg/mL, or 4 pg/mL to 6 pg/mL; and in nasal mucus, can be or about 0.05pg/mL to 0.1 pg/mL, or 0.75 pg/mL to 0.125 pg/mL, 0.05 pg/mL to 0.1pg/mL, or 0.75 pg/mL to 0.125 pg/mL, or 0.1 pg/mL to 0.2 pg/mL, or 0.15pg/mL to 0.3 pg/mL, or 0.2 pg/mL to 0.4 pg/mL, or 0.3 pg/mL to 0.5pg/mL, or 0.4 pg/mL to 0.6 pg/mL, 0.5 pg/mL to 2.0 pg/mL, or 1.5 pg/mLto 3.0 pg/mL, or 2.5 pg/mL to 4.0 pg/mL, or 3.5 pg/mL to 5.0 pg/mL, or 4pg/mL to 6 pg/mL, or 5 pg/mL to 7 pg/mL, or 6 pg/mL to 8 pg/mL, or 7pg/mL to 9 pg/mL, or 8 pg/mL to 10 pg/mL, or 9 pg/mL to 11 pg/mL, or 10pg/mL to 12 pg/mL, or 11 pg/mL to 13 pg/mL, or 11 pg/mL to 13 pg/mL, or12 pg/mL to 16 pg/mL, or 15 pg/mL to 25 pg/mL, or 20 pg/mL to 40 pg/mL);(i) the level of IL-18 that can be or about: 40 pg/mL to 290 pg/mL, 100pg/mL to 230 pg/mL, 40 pg/mL to 230 pg/mL, or 100 pg/mL to 290 pg/mL(e.g., by way of example only, in nasal mucus and saliva, can be fromabout: 0.1 pg/mL to 0.5 pg/mL, or 0.25 pg/mL to 0.75 pg/mL, or 0.6 pg/mLto 0.9 pg/mL, or 0.7 pg/mL to 1.0 pg/mL, or 0.9 pg/mL to 1.5 pg/mL, or1.25 pg/mL to 2.0 pg/mL, or 1.75 pg/mL to 2.5 pg/mL, or 2.4 pg/mL to 3.0pg/mL, 2.7 pg/mL to 3.5 pg/mL or 3.4 pg/mL to 4.5 pg/mL, or 4.0 pg/mL to5.0 pg/mL, or 4.6 pg/mL to 5.5 pg/mL, or 5.4 pg/mL to 6.0 pg/mL, or 5.9pg/mL to 6.5 pg/mL, or 6.4 pg/mL to 7.0 pg/mL, or 6.9 pg/mL to 7.5pg/mL, or 7.4 pg/mL to 8.0 pg/mL, or 7.9 pg/mL to 8.5 pg/mL, or 8.4pg/mL to 9.0 pg/mL, or 8.9 pg/mL to 9.5 pg/mL, or 9.4 pg/mL to 10.0pg/mL, from 9.0 pg/mL to 15.0 pg/mL, or 14.0 pg/mL to 20.0 pg/mL, or19.0 pg/mL to 25.0 pg/mL, or 24.0 pg/mL to 30.0 pg/mL, or 29.0 pg/mL to35.0 pg/mL, or 34.0 pg/mL to 40.0 pg/mL, or 39.0 pg/mL to 45.0 pg/mL, or44.0 pg/mL to 50.0 pg/mL, 50 pg/mL to 100 pg/mL, 75 pg/mL to 150 pg/mL,125 pg/mL to 200 pg/mL, 175 pg/mL to 250 pg/mL, 225 pg/mL to 300 pg/mL,275 pg/mL to 350 pg/mL, 325 pg/mL to 400 pg/mL, 375 pg/mL to 450 pg/mL,425 pg/mL to 500 pg/mL, 475 pg/mL to 550 pg/mL, 525 pg/mL to 600 pg/mL,575 pg/mL to 650 pg/mL; in plasma from: 10 pg/mL to 30 pg/mL, 20 pg/mLto 40 pg/mL, 35 pg/ml to 60 pg/mL, 50 pg/mL to 100 pg/mL, 75 pg/mL to150 pg/mL, 125 pg/mL to 200 pg/mL, 175 pg/mL to 250 pg/mL, 225 pg/mL to300 pg/mL, 275 pg/mL to 350 pg/mL, 325 pg/mL to 400 pg/mL, 375 pg/mL to450 pg/mL, 425 pg/mL to 500 pg/mL, 475 pg/mL to 550 pg/mL, 525 pg/mL to600 pg/mL, 575 pg/mL to 650 pg/mL, 625 pg/mL to 700 pg/mL, 675 pg/mL to750 pg/mL, 725 pg/mL to 800 pg/mL, 775 pg/mL to 850 pg/mL, 825 pg/mL to900 pg/mL, 875 pg/mL to 950 pg/mL, 925 pg/mL to 1000 pg/mL; (j) thelevel of TNF-α that can be or about: 3 pg/mL to 13 pg/mL, 6 pg/mL to 10pg/mL, 6 pg/mL to 13 pg/mL, or 3 pg/mL to 10 pg/mL (e.g., by way ofexample only, in nasal mucus, plasma, saliva, and urine, can be aboutfrom: greater than 0 to 0.025, 0.02 to 0.06, 0.05 pg/mL to 0.1 pg/mL, or0.75 pg/mL to 0.125 pg/mL, or 0.1 pg/mL to 0.2 pg/mL, or 0.15 pg/mL to0.3 pg/mL, or 0.2 pg/mL to 0.4 pg/mL, or 0.3 pg/mL to 0.5 pg/mL, or 0.4pg/mL to 0.6 pg/mL, or 0.5 pg/mL to 0.7 pg/mL, or 0.6 pg/mL to 0.8pg/mL, or 0.7 pg/mL to 0.9 pg/mL, or 0.8 pg/mL to 1.0 pg/mL, or 0.5pg/mL to 2.0 pg/mL, or 1.5 pg/mL to 3.0 pg/mL, or 2.5 pg/mL to 4.0pg/mL, or 3.5 pg/mL to 5.0 pg/mL, or 4 pg/mL to 6 pg/mL; and in nasalmucus, can be or about 0.5 pg/mL to 2.0 pg/mL, or 1.5 pg/mL to 3.0pg/mL, or 2.5 pg/mL to 4.0 pg/mL, or 3.5 pg/mL to 5.0 pg/mL, or 4 pg/mLto 6 pg/mL, or 5 pg/mL to 7 pg/mL, or 6 pg/mL to 8 pg/mL, or 7 pg/mL to9 pg/mL, or 8 pg/mL to 10 pg/mL, or 9 pg/mL to 11 pg/mL, or 10 pg/mL to12 pg/mL, or 11 pg/mL to 13 pg/mL, or 11 pg/mL to 13 pg/mL, or 12 pg/mLto 16 pg/mL, or 15 pg/mL to 25 pg/mL, or 20 pg/mL to 40 pg/mL, or 30pg/mL to 50 pg/mL); (k) the level of IFN-β that can be or about: 0 pg/mLto 910 pg/mL, 230 pg/mL to 680 pg/mL, 230 pg/mL to 910 pg/mL, or 0 pg/mLto 680 pg/mL (e.g., by way of example only, in saliva can be from about:0 to 0.025, 0.02 to 0.06, 0.05 pg/mL to 0.1 pg/mL, or 0.75 pg/mL to0.125 pg/mL, or 0.1 pg/mL to 0.2 pg/mL, or 0.15 pg/mL to 0.3 pg/mL, or0.2 pg/mL to 0.4 pg/mL, or 0.3 pg/mL to 0.5 pg/mL, or 0.4 pg/mL to 0.6pg/mL, or 0.5 pg/mL to 0.7 pg/mL, or 0.6 pg/mL to 0.8 pg/mL, or 0.7pg/mL to 0.9 pg/mL, or 0.8 pg/mL to 1.0 pg/mL, or 0.5 pg/mL to 2.0pg/mL, or 1.5 pg/mL to 3.0 pg/mL, or 2.5 pg/mL to 4.0 pg/mL, or 3.5pg/mL to 5.0 pg/mL, or 4 pg/mL to 6 pg/mL, 5 pg/mL to 8 pg/mL, or 7pg/mL to 9 pg/mL, or 8 pg/mL to 10 pg/mL, or 9 pg/mL to 11 pg/mL, or 10pg/mL to 12 pg/mL, or 11 pg/mL to 13 pg/mL, or 11 pg/mL to 13 pg/mL, or12 pg/mL to 16 pg/mL, or 15 pg/mL to 25 pg/mL, or 20 pg/mL to 40 pg/mL,or 30 pg/mL to 50 pg/mL; 49 pg/mL to 55 pg/mL, or 54 pg/mL to 60 pg/mL,or 59 pg/mL to 65 pg/mL, or 64 pg/mL to 70 pg/mL, or 69 pg/mL to 75pg/mL, 74 pg/mL to 80 pg/mL, or 79 pg/mL to 85 pg/mL, or 84 pg/mL to 90pg/mL, or 89 pg/mL to 95 pg/mL, or 94 pg/mL to 100 pg/mL, or 99 pg/mL to105 pg/mL, 104 pg/mL to 110 pg/mL, or 109 pg/mL to 105 pg/mL, or 104pg/mL to 110 pg/mL, or 109 pg/mL to 115 pg/mL, or 114 pg/mL to 120pg/mL, or 119 pg/mL to 125 pg/mL, 124 pg/mL to 130 pg/mL, or 129 pg/mLto 135 pg/mL, or 134 pg/mL to 140 pg/mL, or 139 pg/mL to 145 pg/mL, or144 pg/mL to 150 pg/mL; 125 pg/mL to 200 pg/mL, 175 pg/mL to 250 pg/mL,225 pg/mL to 300 pg/mL, 275 pg/mL to 350 pg/mL, 325 pg/mL to 400 pg/mL,375 pg/mL to 450 pg/mL, 425 pg/mL to 500 pg/mL; in nasal mucus andplasma from about: 50 pg/mL to 100 pg/mL, 75 pg/mL to 150 pg/mL, 125pg/mL to 200 pg/mL, 175 pg/mL to 250 pg/mL, 225 pg/mL to 300 pg/mL, 275pg/mL to 350 pg/mL, 325 pg/mL to 400 pg/mL, 375 pg/mL to 450 pg/mL, 425pg/mL to 500 pg/mL, 475 pg/mL to 550 pg/mL, 525 pg/mL to 600 pg/mL, 575pg/mL to 650 pg/mL, 625 pg/mL to 700 pg/mL; in plasma, from: 100 pg/mLto 500 pg/mL, 400 pg/mL to 1000 pg/mL, 900 pg/mL to 1500 pg/mL, 1400pg/mL to 2000 pg/mL, 1900 pg/mL to 2500 pg/mL, 2400 pg/mL to 3000 pg/mL,2900 pg/mL to 3500 pg/mL, 3400 pg/mL to 4000 pg/mL, 3900 pg/mL to 4500pg/mL, 4400 pg/mL to 5000 pg/mL, 4900 pg/mL to 5500 pg/mL, 5400 pg/mL to6000 pg/mL, 5900 pg/mL to 6500 pg/mL, 6400 pg/mL to 7000 pg/mL, 6900pg/mL to 7500 pg/mL, 7400 pg/mL to 8000 pg/mL, 7900 pg/mL to 8500 pg/mL,8400 pg/mL to 9000 pg/mL, 8900 pg/mL to 9500 pg/mL, 9400 pg/mL to 10,000pg/mL; or (1) the level of IFN-γ that can be or about: 55 pg/mL to 110pg/mL, 70 pg/mL to 95 pg/mL, 70 pg/mL to 110 pg/mL, 55 pg/mL to 95pg/mL, 0.1 pg/mL to 3 pg/mL, 2.5 pg/mL to 4 pg/mL, 3.5 pg/mL to 6 pg/mL,5 pg/mL to 10 pg/mL, 9 pg/mL to 15 pg/mL, 14 pg/mL to 20 pg/mL, or 19pg/mL to 25 pg/mL, or 24 pg/mL to 30 pg/mL, or 29 pg/mL to 35 pg/mL, or34 pg/mL to 40 pg/mL, or 39 pg/mL to 45 pg/mL, 44 pg/mL to 50 pg/mL, or49 pg/mL to 55 pg/mL, or 54 pg/mL to 60 pg/mL, or 59 pg/mL to 65 pg/mL,or 64 pg/mL to 70 pg/mL, or 69 pg/mL to 75 pg/mL, 74 pg/mL to 80 pg/mL,or 79 pg/mL to 85 pg/mL, or 84 pg/mL to 90 pg/mL, or 89 pg/mL to 95pg/mL, or 94 pg/mL to 100 pg/mL, or 99 pg/mL to 105 pg/mL, 104 pg/mL to110 pg/mL, or 109 pg/mL to 105 pg/mL, or 104 pg/mL to 110 pg/mL, or 109pg/mL to 115 pg/mL, or 114 pg/mL to 120 pg/mL, or 119 pg/mL to 125pg/mL, 124 pg/mL to 130 pg/mL, or 129 pg/mL to 135 pg/mL, or 134 pg/mLto 140 pg/mL, or 139 pg/mL to 145 pg/mL, or 144 pg/mL to 150 pg/mL, 149pg/mL to 200 pg/mL.

The methods can be based upon 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 ofone or more measurements.

The methods can further comprise evaluating the subject's gustatoryand/or olfactory function by determining a detection threshold (DT)score, a recognition threshold (RT) score, a magnitude estimation (ME)score, or any combination thereof with a forced-choice, three-stimuli,stepwise-staircase technique using one or more gustatory and/orolfaction testing compounds. Gustatory testing compounds can compriseany substance that is salty, sweet, bitter, sour, or umami, for example,sugar (such as sucrose, glucose, fructose, and lactose), salt (such assodium chloride), acids (such as hydrochloric acid and citric acid),quinine (e.g., quinine sulfate), and monosodium glutamate. Anysubstances that can evoke a salty, sweet, bitter, sour, or umamisensation, can be used as a test substance, and therefore is explicitlycontemplated. The one or more olfaction testing compounds can comprisepyridine, nitrobenzene, thiophene, amyl acetate, or any combinationthereof. The diagnosing can be further based upon the DT score beinghigher than an average DT score as measured in the control populationcomprising subject with normal olfactory function, the RT score beinghigher than an average RT score as measured in the control populationcomprising subject with normal olfactory function, and/or the ME scorebeing lower than an average ME score as measured in the controlpopulation comprising subject with normal olfactory function.

After diagnosing a subject with loss and/or distortion of taste orsmell, e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia,dysgeusia, phantogeusia, and/or ageusia, based on one or more of thepreviously described diagnostics methods, subjects can be treated toameliorate and/or cure their loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia conditions. The diagnostic methods aresupplemented with treatment of loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia. The diagnostic methods can furthercomprise treating the loss and/or distortion of taste or smell, e.g.,hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia in the subject diagnosed with loss and/ordistortion of taste or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia can be asubject in need thereof.

The methods of this invention can further comprise at least one of: (a)treating the subject diagnosed with loss and/or distortion of taste orsmell, e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia,dysgeusia, phantogeusia, and/or ageusia; (b) transferring the e.g.,diagnosed, result via a communication medium; and/or (c) computerimplementing the diagnosis.

The treating can comprise administering to the subject e.g., in needthereof, at least one therapeutic agent.

The at least one therapeutic agent can be a PDE inhibitor.“Phosphodiesterase inhibitor” or “PDE inhibitor” can refer to anycompound that inhibits a phosphodiesterase enzyme, isozyme or allozyme.The term can refer to selective or non-selective inhibitors of cyclicguanosine 3′,5′-monophosphate phosphodiesterases (cGMP-PDE) and/orcyclic adenosine 3′,5′-monophosphate phosphodiesterases (cAMP-PDE).

Theophylline and papaverine are representative members of non-selectivePDE inhibitors that can be prescribed orally to treat asthma and chronicobstructive pulmonary disease (COPD) through the relaxation of smoothmuscle in the airways. Theophylline has anti-inflammatory effects on theairways that can be useful to combat the abnormal inflammation seen inasthmatics. Most importantly, this anti-inflammatory effect can beobtained at levels in the blood well below that which causes the commonside effects seen in most people. Patients with emphysema and chronicbronchitis can also be helped with theophylline when their symptoms arepartially related to reversible airway narrowing.

Theophylline is a methylxanthine derivative; other non-selectivephosphodiesterase inhibitors in this class can include caffeine, IBMX(3-isobutyl-1-methylxanthine, aminophylline, doxophylline,cipamphylline, theobromine, pentoxifylline (oxpentifylline) anddiprophylline.

PDE1 selective inhibitors formerly known as calcium- andcalmodulin-dependent phosphodiesterases can includeeburnamenine-14-carboxylic acid ethyl ester (vinpocetine), which can beused to induce vasorelaxation on cerebral smooth muscle tissue. OtherPDE-1 selective inhibitors can include compound KS505a, bepril,flunarizine, amiodarone, zaprinast, 8-methoxymethyl IPMX, SCH 51866,Nimodipine, and IC224.

PDE2 decreases aldosterone secretion and can play an important role inthe regulation of elevated intracellular concentrations of cAMP and cGMPin platelets. Several regions of the brain can express PDE2 and ratexperiments indicate that inhibition of PDE2 enhances memory. PDE2 mayplay a role in regulation of fluid and cell extravasation duringinflammatory conditions as PDE2 can be localized to microvessels,especially venous capillary and endothelial cells, but apparently not tolarger vessels. PDE2 can also be a pharmacological target forpathological states such as sepsis or in more localized inflammatoryresponses such as thrombin-induced edema formation in the lung. PDE-2selective inhibitors can include EHNA (erythro-9-(2-hydroxy-3-nonyl)adenine), 9-(6-phenyl-2-oxohex-3-yl)-2-(3,4-dimethoxybenzyl)-purin-6-one(PDP), and BAY 60-7750.

The PDE3 family hydrolyzes cAMP and cGMP, but in a manner suggestingthat in vivo, the hydrolysis of cAMP can be inhibited by cGMP. They alsoare distinguished by their ability to be activated by severalphosphorylation pathways including the PKA and PI3K/PKB pathways. PDE3Acan be relatively highly expressed in platelets, as well as in cardiacmyocytes and oocytes. PDE3B can be a major PDE in adipose tissue, liver,and pancreas, as well as in several cardiovascular tissues. Both PDE3Aand PDE3B can be highly expressed in vascular smooth muscle cells andmay likely modulate contraction.

PDE3 inhibitors can mimic sympathetic stimulation to increase cardiacinotropy, chronotropy and dromotropy. PDE3 inhibitors can alsoantagonize platelet aggregation, increase myocardial contractility,and/or enhance vascular and airway smooth muscle relaxation. PDE3A canbe a regulator of this process and PDE3 inhibitors can effectivelyprevent aggregation of platelets. Cilastazol (Pletal), is approved fortreatment of intermittent claudication. Without being limited by theory,the mechanism of Cilastazol action is thought to involve inhibition ofplatelet aggregation along with inhibition of smooth muscleproliferation and vasodilation. PDE3-selective inhibitors can includeenoximone, milrinone (Primacor), amrinone, cilostamide, cilostazol(Pletal), trequinsin, inamrinone, anagrelide, pimobendan, lixazinone,and dihydro-pyridazinone.

PDE4 inhibitors can effectively suppress release of inflammatorymediators (e.g., cytokines) and can inhibit the production of reactiveoxygen species and immune cell infiltration. PDE4-selective inhibitorscan include mesembrine; rolipram; Ibudilast, a neuroprotective andbronchodilator drug used mainly in the treatment of asthma and stroke;roflumilast (Daxas), cilomilast (Airflo), piclamilast, luteolin,drotaverine, and denbufylline. PDE4 inhibitors can be effective intreating asthma, arthritis, and psoriasis.

PDE5s can regulate vascular smooth muscle contraction and can be themolecular target for drugs that can be used to treat erectiledysfunction and/or pulmonary hypertension. In the lung, inhibition ofPDE5 can oppose smooth muscle vasoconstriction. PDE5 inhibitors can beused to treat pulmonary hypertension.

PDE5-selective inhibitors can include sildenafil, tadalafil, vardenafil,udenafil and avanafil, dipyridamole, icariin, 4-Methylpiperazine,Pyrazolo Pyrimidin-7-1, cilomilast, and zaprinast.

PDE6-selective inhibitors can include zaprinast, dipyridamole,vardenafil, and tadalafil.

PDE7-selective inhibitors can include quinazoline type PDE7 inhibitor,dipyridamole, and thiadiazole.

PDE8-selective inhibitors can include dipyridamole.

PDE9-selective inhibitors can include zaprinast.

PDE10-selective inhibitors can include papaverine, OMS824, PF-2545920,and dipyridamole.

PDE11-selective inhibitors can include tadalafil, zaprinast, anddipyridamole.

PDE inhibitors can inhibit cellular apoptosis. Without being limited bytheory, the mechanism of apoptosis inhibition can include inhibition ofTNF alpha, TRAIL and their metabolites. PDE inhibitors can activate theproduction and secretion of nitric oxide in tissues, which can inducevasorelaxation or vasodilation of blood vessels (e.g., peripheral bloodvessels, thereby inhibiting intermittent claudication; the distalextremities; and in the penile region, contributing to penile erection).

PDE inhibitors useful in the present invention can include, for example,filaminast, piclamilast, rolipram, Org 20241, MCI-154, roflumilast,toborinone, posicar, lixazinone, zaprinast, sildenafil,pyrazolopyrimidinones (such as those disclosed in WO 98/49166),motapizone, pimobendan, zardaverine, siguazodan, CI-930, EMD 53998,imazodan, saterinone, loprinone hydrochloride, 3-pyridinecarbonitrilederivatives, denbufyllene, albifylline, torbafylline, doxofylline,theophylline, pentoxofylline, nanterinone, cilostazol, cilostamide, MS857, piroximone, milrinone, aminone, tolafentrine, dipyridamole,papaverine, E4021, thienopyrimidine derivatives (such as those disclosedin WO 98/17668), triflusal, ICOS-351,tetrahydropiperazino[1,2-b]beta-carboline-1,4-dione derivatives (such asthose disclosed in U.S. Pat. No. 5,859,006, WO 97/03985 and WO97/03675), carboline derivatives, (such as those disclosed in WO97/43287), 2-pyrazolin-5-one derivatives (such as those disclosed inU.S. Pat. No. 5,869,516), fused pyridazine derivatives (such as thosedisclosed in U.S. Pat. No. 5,849,741), quinazoline derivatives (such asthose disclosed in U.S. Pat. No. 5,614,627), anthranilic acidderivatives (such as those disclosed in U.S. Pat. No. 5,714,993),imidazoquinazoline derivatives (such as those disclosed in WO 96/26940),and the like, incorporated herein by reference in their entirety. Alsoincluded are those phosphodiesterase inhibitors disclosed in WO 99/21562and WO 99/30697, incorporated herein by reference in their entirety. Itis contemplated that at certain times, the intranasal composition doesnot comprise a PDE5 selective inhibitor.

Theophylline is an exemplary PDE inhibitor that can be administeredaccording to the methods disclosed herein. For example, 20 μg/naris oftheophylline can be administered twice daily. 40 μg/naris oftheophylline can also be administered once daily. 40 μg/naris oftheophylline can also be administered twice daily. 80 μg/naris oftheophylline can also be administered once daily. 80 μg/naris oftheophylline can also be administered twice daily.

The administration of an effective amount of a PDE inhibitor such astheophylline by intranasal administration may not produce a detectableblood level of the PDE inhibitor. The overall level of PDE inhibitioncan be measured by methods known in the art. For example, methods thatcan be used to determine the level of PDE, measure the downstreamtargets of PDE. Commercial tests can also be used. For example, aphosphodiesterase assay can be used as described in Lu et al., CellPhysiology, 2012, V302:C59-C66, incorporated herein by reference in itsentirety. The administration of an effective amount of a PDE inhibitorby intranasal administration can produce blood concentrations of the PDEinhibitor that can be less than 5 mg/dl, 2 mg/dl, 1 mg/dl, 500 μg/dl,250 μg/dl, 100 μg/dl, 50 μg/dl, 25 μg/dl, 10 μg/dl, 5 μg/dl, or 1 μg/dl.

Intranasal administration of an effective amount of a PDE inhibitor suchas theophylline can increase taste or smell acuity. The increase intaste or smell acuity can be at least 5%, 10%, 20%, 30%, 40%, 50%, 75%,or 100% compared to the untreated state. Taste or smell acuity can beincreased to at least 5%, 10%, 20%, 30%, 40%, 50%, 75%, or 100% of theacuity of normal individuals. Taste or smell acuity can be measuredobjectively, while in other embodiments taste or smell acuity can bemeasured subjectively. According to the NIH(www.nlm.nih.gov/medlinepluse/druginfo/meds/a681006.html) the use of PDEinhibitors such as theophylline can be associated with side effects suchas upset stomach, stomach pain, diarrhea, headache, restlessness,insomnia, irritability, vomiting, increased or rapid heart rate,irregular heartbeat, seizures, and/or skin rash. Intranasaladministration of PDE inhibitors such as theophylline can cause fewerside effects than other routes of administration. Intranasaladministration of PDE inhibitors such as theophylline can cause lesssevere side effects than other routes of administration.

PDE inhibitors such as theophylline can be administered alone or incombination with one or more other active ingredients; for example, 1,2, 3, 4, 5, 6, 7, 8, 9, 10 or more other active ingredients, such as anydrug disclosed herein. For example, other selective or non-selective PDEinhibitors can be used, or drugs such as forskolin and riociguat can beused.

The at least one PDE inhibitor can be a non-selective PDE inhibitor, aPDE-1 selective inhibitor, a PDE-2 selective inhibitor, a PDE-3selective inhibitor, a PDE-4 selective inhibitor, a PDE-5 selectiveinhibitor, a PDE-10 selective inhibitor, or any combination thereof. Theat least one PDE inhibitor can be a non-selective PDE inhibitor that canbe a methylxanthine derivative. The methylxanthine derivative can becaffeine, theophylline, doxophylline, cipamphylline, neuphylline,pentoxiphylline, or diprophylline. The methylxanthine derivative can betheophylline. The PDE 1 inhibitor can be vinpocetine, compound KS505a,bepril, flunarizine, amiodarone, zaprinast, 8-methoxymethyl IPMX, SCH51866, Nimodipine, or IC224. The PDE 2 inhibitor can be EHNA. The PDE 3inhibitor can be enoximone, milrinone (Primacor), amrinone, cilostamide,cilostazol (Pletal), trequinsin, inamrinone, anagrelide, pimobendan,lixazinone, or dihydro-pyridazinone. The PDE 4 inhibitor can bemesembrine, rolipram, ibudilast, roflumilast (Daxas), cilomilast(Airflo), piclamilast, luteolin, drotaverine, or denbufylline. The PDE 5inhibitor can be sildenafil, tadalafil, vardenafil, udenafil andavanafil, dipyridamole, icariin, 4-Methylpiperazine, PyrazoloPyrimidin-7-1, cilomilast, or zaprinast. The PDE6-selective inhibitorscan be zaprinast, dipyridamole, vardenafil, or tadalafil. ThePDE7-selective inhibitors can be quinazoline type PDE7 inhibitor,dipyridamole, or thiadiazole. The PDE8-selective inhibitors can bedipyridamole. The PDE9-selective inhibitors can be zaprinast. The PDE 10inhibitor can be papaverine, OMS824 (from Omeros Corporation), and/orPF-2545920 (from Pfizer). The PDE11-selective inhibitors can betadalafil, zaprinast, or dipyridamole. Any combination of one or morePDE inhibitors, as described herein, can be used.

Forskolin is a labdane diterpene that is produced by the plant Coleusforskohlii. Forskolin can be used to raise levels of cAMP levels. Themechanism can comprise activating adenylyl cyclase.

Riociguat, also known as BAY 63-2521, can be used as a guanylate cyclase(sGC) stimulator. At specific milligram oral dosages, riociguat isbelieved to be helpful in treating two forms of pulmonary hypertension(PH): chronic thromboembolic pulmonary hypertension (CTEPH) andpulmonary arterial hypertension (PAH).

The methods described herein can further comprise treating the subject,i.e., in need thereof, with at least one therapeutic agent, wherein theat least one therapeutic agent can be a non-selective PDE inhibitor,forskolin, and/or riociguat. Various combinations are contemplated. Byway of example, several methods are disclosed herein. The methods canfurther comprise treating the subject in need thereof with at least onetherapeutic agent, wherein the at least one therapeutic agent can be aselective PDE inhibitor, forskolin, and/or riociguat. The methods canfurther comprise treating the subject in need thereof with at least onetherapeutic agent, wherein the at least one therapeutic agent can be anon-selective PDE inhibitor, theophylline, and/or riociguat. The methodscan further comprise treating the subject in need thereof with at leastone therapeutic agent, wherein the at least one therapeutic agent cancomprise a selective PDE inhibitor, theophylline, and/or riociguat. Themethods can further comprise treating the subject in need thereof withat least one therapeutic agent, wherein the at least one therapeuticagent can comprise a non-selective PDE inhibitor and/or riociguat. Themethods can further comprise treating the subject in need thereof withat least one therapeutic agent, wherein the at least one therapeuticagent can comprise a selective PDE inhibitor and/or riociguat. Themethods can further comprise treating the subject in need thereof withat least one therapeutic agent, wherein the at least one therapeuticagent can comprise theophylline and/or riociguat. The methods canfurther comprise at least one therapeutic agent, wherein the at leastone therapeutic agent can comprise forskolin and/or riociguat. Themethods can further comprise at least one therapeutic agent, wherein theat least one therapeutic agent can comprise theophylline, forskolin,and/or riociguat. The methods can further comprise at least onetherapeutic agent, wherein the at least one therapeutic agent cancomprise riociguat. The methods can further comprise at least onetherapeutic agent, wherein the at least one therapeutic agent cancomprise theophylline. The methods can further comprise at least onetherapeutic agent, wherein the at least one therapeutic agent cancomprise forskolin. The methods can further comprise at least onetherapeutic agent, wherein the at least one therapeutic agent cancomprise a non-selective PDE inhibitor. The methods can further compriseat least one therapeutic agent, wherein the at least one therapeuticagent can comprise a selective PDE inhibitor.

Riociguat can be used to effectively treat loss and/or distortion oftaste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia,hypogeusia, dysgeusia, phantogeusia, and/or ageusia. In particular,effective dosages of riociguat can differ from high to low levels.Riociguat can be given and/or present in an amount selected from a groupconsisting of: greater than 0.0 μg to 1 μg, 0.5 μg to 2 μg, 1.5 μg to3.0 μg, 2.5 μg to 10 μg, 5 μg to 15 μg, 12.5 μg to 30 μg, 25 μg to 50μg, 40 μg to 80 μg, 60 μg to 100 μg, 90 μg to 120 μg, 110 μg to 130 μg,125 μg to 150 μg, 140 μg to 180 μg, 170 μg to 200 μg, 200 μg to 230 μg,215 μg to 240 μg, 235 μg to less than 250 μg, and less than 250 μg, andgreater than about 0.0 μg to about 1 μg, about 0.5 μg to about 2 μg,about 1.5 μg to about 3.0 μg, about 2.5 μg to about 10 μg, about 5 μg toabout 15 μg, about 12.5 μg to about 30 μg, about 25 μg to about 50 μg,about 40 μg to about 80 μg, about 60 μg to about 100 μg, about 90 μg toabout 120 μg, about 110 μg to about 130 μg, about 125 μg to about 150μg, about 140 μg to about 180 μg, about 170 μg to about 200 μg, about200 μg to about 230 μg, about 215 μg to about 240 μg, and about 235 μgto less than 250 μg.

Theophylline can be used to effectively treat loss and/or distortion oftaste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia,hypogeusia, dysgeusia, phantogeusia, and/or ageusia. In particular,effective dosages of theophylline can differ from high to low levels.Theophylline can be given and/or present in an amount selected from agroup consisting of: less than 45 mg, 30 mg, 15 mg, 10 mg, 5 mg, 1 mg,500 μg, 250 μg, 120 μg, 80 μg, 40 μg, or 20 μg and less than about 45mg, about 30 mg, about 15 mg, about 10 mg, about 5 mg, about 1 mg, about500 μg, about 250 μg, about 120 μg, about 80 μg, about 40 μg, or about20 pg.

Forskolin can be used to effectively treat loss and/or distortion oftaste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia,hypogeusia, dysgeusia, phantogeusia, and/or ageusia. In particular,effective dosages of forskolin can differ from high to low levels.Forskolin can be given and/or present in an amount selected from a groupconsisting of: less than 500 mg to 450 mg, 475 mg to 425 mg, 435 mg to400 mg, 415 mg to 300 mg, 325 mg to 250 mg, 275 mg to 150 mg, 200 mg to100 mg, 135 mg to 80 mg, 95 mg to 65 mg, 75 mg to 50 mg, 60 mg to 40 mg,45 mg to 25 mg, 30 mg to 20 mg, 15 mg to 5 mg, 10 mg to 2.5 mg, 3.5 mgto 1 mg, and 2 mg to greater than 0 mg, and less than about 500 mg toabout 450 mg, about 475 mg to about 425 mg, about 435 mg to about 400mg, about 415 mg to about 300 mg, about 325 mg to about 250 mg, about275 mg to about 150 mg, about 200 mg to about 100 mg, about 135 mg toabout 80 mg, about 95 mg to about 65 mg, about 75 mg to about 50 mg,about 60 mg to about 40 mg, about 45 mg to about 25 mg, about 30 mg toabout 20 mg, about 15 mg to about 5 mg, about 10 mg to about 2.5 mg,about 3.5 mg to about 1 mg, and about 2 mg to greater than 0 mg.

Any combination of riociguat, theophylline, and/or forskolin can begiven to a subject e.g., in need thereof. In certain cases, a particularcombination of riociguat, theophylline, and/or forskolin can exhibitsynergistic effects when treating conditions, compared to when treatingwith riociguat, theophylline, and/or forskolin alone. In other cases, aparticular combination of riociguat, theophylline, and/or forskolin canexhibit synergistic effects when treating conditions, compared to whentreating with riociguat, theophylline, and/or forskolin in pairs. Theconditions can be disease. The condition can be loss and/or distortionof taste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia,hypogeusia, dysgeusia, phantogeusia, and/or ageusia. The methods cancomprise treating subjects with one or more therapeutic agents, wherein:(a) riociguat can be given and/or present in an amount selected from agroup consisting of: greater than 0.0 μg to 1 μg, 0.5 μg to 2 μg, 1.5 μgto 3.0 μg, 2.5 μg to 10 μg, 5 μg to 15 μg, 12.5 μg to 30 μg, 25 μg to 50μg, 40 μg to 80 μg, 60 μg to 100 μg, 90 μg to 120 μg, 110 μg to 130 μg,125 μg to 150 μg, 140 μg to 180 μg, 170 μg to 200 μg, 200 μg to 230 μg,215 μg to 240 μg, 235 μg to less than 250 μg, and less than 250 μg, andgreater than about 0.0 μg to about 1 μg, about 0.5 μg to about 2 μg,about 1.5 μg to about 3.0 μg, about 2.5 μg to about 10 μg, about 5 μg toabout 15 μg, about 12.5 μg to about 30 μg, about 25 μg to about 50 μg,about 40 μg to about 80 μg, about 60 μg to about 100 μg, about 90 μg toabout 120 μg, about 110 μg to about 130 μg, about 125 μg to about 150μg, about 140 μg to about 180 μg, about 170 μg to about 200 μg, about200 μg to about 230 μg, about 215 μg to about 240 μg, and about 235 μgto less than 250 μg; (b) theophylline can be given and/or present in anamount selected from a group consisting of: less than 45 mg, 30 mg, 15mg, 10 mg, 5 mg, 1 mg, 500 μg, 250 μg, 120 μg, 80 μg, 40 μg, or 20 μgand less than about 45 mg, about 30 mg, about 15 mg, about 10 mg, about5 mg, about 1 mg, about 500 μg, about 250 μg, about 120 μg, about 80 μg,about 40 μg, or about 20 μg; and (c) forskolin can be given and/orpresent in an amount selected from a group consisting of: less than 500mg to 450 mg, 475 mg to 425 mg, 435 mg to 400 mg, 415 mg to 300 mg, 325mg to 250 mg, 275 mg to 150 mg, 200 mg to 100 mg, 135 mg to 80 mg, 95 mgto 65 mg, 75 mg to 50 mg, 60 mg to 40 mg, 45 mg to 25 mg, 30 mg to 20mg, 15 mg to 5 mg, 10 mg to 2.5 mg, 3.5 mg to 1 mg, and 2 mg to greaterthan 0 mg, and less than about 500 mg to about 450 mg, about 475 mg toabout 425 mg, about 435 mg to about 400 mg, about 415 mg to about 300mg, about 325 mg to about 250 mg, about 275 mg to about 150 mg, about200 mg to about 100 mg, about 135 mg to about 80 mg, about 95 mg toabout 65 mg, about 75 mg to about 50 mg, about 60 mg to about 40 mg,about 45 mg to about 25 mg, about 30 mg to about 20 mg, about 15 mg toabout 5 mg, about 10 mg to about 2.5 mg, about 3.5 mg to about 1 mg, andabout 2 mg to greater than 0 mg.

The cytochrome P450 superfamily (CYP) can be a large and diverse groupof enzymes that catalyze the oxidation of organic substances. CYPs arethe major enzymes involved in drug metabolism and bioactivation. Theinventors have found that by inhibiting CYPs, the effect of thetherapeutic agents of this invention can be prolonged and have a moreprofound effect. This can allow for lower dosing and delivery via amultitude of different routes of administration. The inventors have alsofound that different routes of administration may circumvent drugresistance.

The methods can further comprise treating a subject in need thereof,wherein the treating can comprise administering to a subject, aneffective amount of cytochrome p450 inhibitors. The methods can furthercomprise administering to a subject, an effective amount of cytochromep450 inhibitors, wherein the cytochrome p450 inhibitors can fully orpartially inhibit a cytochrome selected from a group consisting of:CYP1, CYP1A1, CYP1A2, CYP1B1, CYP2, CYP2A6, CYP2A7, CYP2A13, CYP2B6,CYP2C8, CYP2C9, CYP2C18, CYP2C19, CYP2D6, CYP2E1, CYP2F1, CYP2J2,CYP2R1, CYP2S1, CYP2U1, CYP2W1, CYP3, CYP3A4, CYP3A5, CYP3A7, CYP3A43,CYP4, CYP4A11, CYP4A22, CYP4B1, CYP4F2, CYP4F3, CYP4F8, CYP4F11,CYP4F12, CYP4F22, CYP4V2, CYP4X1, CYP4Z1, CYP5, CYP5A1, CYP7, CYP7A1,CYP7B1, CYP8, CYP8A1, CYP8B1, CYP11, CYP11A1, CYP11B1, CYP11B2, CYP17,CYP17A1, CYP19, CYP19A1, CYP20, CYP20A1, CYP21, CYP21A2, CYP24, CYP24A1,CYP26, CYP26A1, CYP26B1, CYP26C1, CYP27, CYP27A1, CYP27B1, CYP27C1,CYP39, CYP39A1, CYP46, CYP46A1, CYP51, and CYP51A1. The methods can alsofurther comprise administering to a subject, an effective amount ofcytochrome p450 inhibitors, wherein the cytochrome p450 inhibitor canfully or partially inhibit CYP1. The methods can also further compriseadministering to a subject, an effective amount of cytochrome p450inhibitors, wherein the cytochrome p450 inhibitor can fully or partiallyinhibit CYP1A2. The CYP1A2 inhibitor can be selected from a groupconsisting of: fluoroquinolone, selective serotonin reuptake inhibitor(SSRI), calcium channel blocker, herbal tea, naringenin, H2-receptorantagonist, antiarrhythmic agent, interferon, xanthotoxin, mibefradil,cumin, turmeric, and isoniazid. The one or more CYP1A2 inhibitor can begrapefruit juice. The one or more CYP1A2 inhibitor can be naringenin.

β-adrenergic agonists are a class of sympathomimetic agents which canact upon the beta adrenoceptors. Stimulation with β-adrenergic agonistscan activate adenylate cyclase and raise intracellular cAMP levels. Theinventors have found that treatment with β-adrenergic agonists canameliorate loss and/or distortion of taste or smell, e.g., hyposmia,dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia, phantogeusia,and/or ageusia. The methods can further comprise treating a subject inneed thereof, wherein the treating can comprise administering to asubject, an effective amount of one or more β-adrenergic agonists. Theone or more β-adrenergic agonists can be a β₁-adrenergic agonist and/orβ2-adrenergic agonist. The methods can also further comprise one or moreβ-adrenergic agonists, wherein the one or more β-adrenergic agonists canbe a β₁-adrenergic agonist. The one or more β-adrenergic agonists can bea β₁-adrenergic agonist selected from a group consisting of dobutamine,isoproterenol, xamoterol and epinephrine. The one or more β-adrenergicagonists can be a β₂-adrenergic agonist. The one or more β-adrenergicagonists can be a β₂-adrenergic agonist selected from a group consistingof albuterol, levalbuterol, fenoterol, formoterol, isoproterenol (β₁ and(β₂), metaproterenol, salmeterol, terbutaline, clenbuterol, isoetarine,pirbuterol, procaterol, ritodrine, and epinephrine. The one or moreβ-adrenergic agonists can be selected from a group consisting of:arbutamine, befunolol, bromoacetylalprenololmenthane, broxaterol,cimaterol, cirazoline, denopamine, dopexamine, etilefrine,hexoprenaline, higenamine, isoxsuprine, mabuterol, methoxyphenamine,nylidrin, oxyfedrine, prenalterol, ractopamine, reproterol, rimiterol,tretoquinol, tulobuterol, zilpaterol, and zinterol.

Anti-inflammatory cytokines can be used to ameliorate loss and/ordistortion of taste or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia. Themethods can also further comprise treating, wherein the treating cancomprise administering to a subject in need thereof, an effective amountof one or more anti-inflammatory cytokines. The one or moreanti-inflammatory cytokines can comprise IL-1ra, IL-10, IFN-γ, IFN-β, orany combination thereof.

Antibodies or the like, e.g., antibody mimetics and antibody fragmentscan be used to ameliorate loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia. The methods can also further comprisetreating, wherein the treating can comprise administration of aneffective amount of an antibody, antibody fragment, or antibody mimeticthat can inhibit one of the one or more pro-inflammatory cytokines. Theantibody, antibody fragment, or antibody mimetic can bind to one of theone or more pro-inflammatory cytokines. The antibody, antibody fragment,or antibody mimetic can bind to a receptor for at least one of the oneor more pro-inflammatory cytokines. The antibody can be a monoclonalantibody. The monoclonal antibody can be a recombinant antibody, achimeric antibody, a human monoclonal antibody, or a humanizedmonoclonal antibody. The antibody fragment can be a FAB fragment, a FAB2fragment, a Fv fragment, a ScFv fragment, an antibody light chain, or anantibody heavy chain. The antibody mimetic can be an affibody molecule,an affilin, an affitin, an anticalins, an avimers, a DARPins, a fynomer,a Kunitz domain peptide, or a monobody.

It is contemplated that the methods comprise a antibody, antibodyfragment, or antibody mimetic can bind to IL-6. The antibody, antibodyfragment, or antibody mimetic can bind to a receptor for IL-6. Theantibody, antibody fragment, or antibody mimetic can be tociluzumab,sarilumab, elsilimomab, siltuximab, sirukumab, BMS-945429, CDP6038,VX30, ARGX-109, or FM101. The inhibitor can be lunasin. The methods canalso encompass antibodies, antibody fragments, or antibody mimetics thatcan bind to IL-1α. The antibody, antibody fragment, or antibody mimeticcan bind to a receptor for IL-1α. The inhibitor can be IL-1RA. Theantibody, antibody fragment, or antibody mimetic can bind to IL-1β. Theantibody, antibody fragment, or antibody mimetic can bind to a receptorfor IL-1β. The antibody, antibody fragment, or antibody mimetic can becanakinumab. The antibody, antibody fragment, or antibody mimetic canbind to TNF-α. The antibody, antibody fragment, or antibody mimetic canbind to a receptor for TNF-α. The antibody, antibody fragment, orantibody mimetic can be infliximab, adalimumab, certolizumab pegol, orgolimumab. The inhibitor can be etanercept, a xanthine derivative,bupropion, or a 5-HT2A agonist. The inhibitor can be the xanthinederivative that can be pentoxifylline. The inhibitor can be the 5-HT2Aagonist that can be (R)-DOI (2,5-dimethoxy-4-iodoamphetamine), TCB-2(1-[(7R)-3-bromo-2,5-dimethoxybicyclo[4.2.0]octa-1,3,5-trien-7-yl]methanamine),LSD (lysergic acid diethylamide), or LSZ (Lysergic acid2,4-dimethylazetidide).

The methods can further comprise administration of a composition ordosage unit that can be steroid-free.

Another aspect of this invention can be to restore the levels of membersof the hedgehog signaling pathway to a therapeutically effective level.This can be achieved by various methods, including but not limited tothose already known in the art. The treatment can comprise increasingthe level of one or more members of the hedgehog signaling pathway byadministration of an effective amount of one or more members of thehedgehog signaling pathway. The increasing the level of one or moremembers of the hedgehog signaling pathway can also compriseadministration of an effective amount of the one or more exogenousmembers of the hedgehog signaling pathway. The increasing the level ofone or more members of the hedgehog signaling pathway can also compriseactivating expression of an effective amount of one or more members ofthe hedgehog signaling pathway. The activating expression of aneffective amount of one or more members of the hedgehog signalingpathway can be done by genetic manipulation of genes responsible for theexpression of one or more members of the hedgehog signaling pathway. Theactivating expression of an effective amount of one or more members ofthe hedgehog signaling pathway can also be effectuated through atherapeutic agent. The treatment can directly or indirectly affectlevels of one or more members of the hedgehog signaling pathway.

The methods of this invention can include different routes ofadministration for the one or more therapeutic agents. Known methods inthe art can be used to make different formulations. The one or moretherapeutic agents or composition comprising one or more therapeuticagents can be suitable for administration by a methods selected from agroup consisting of: oral administration, transmucosal administration,buccal administration, inhalation administration, intranasaladministration, parental administration, intravenous administration,subcutaneous administration, intramuscular administration, sublingualadministration, transdermal administration, and rectal administration.Because of the ease of use, the one or more therapeutic agents orcomposition comprising one or more therapeutic agents can be suitablefor oral administration, inhalational administration, intranasaladministration, or any combination thereof.

The subject of this invention can be a mammal. For example, the subjectcan be a human. The subject can be a subject in need thereof.

Methods for Treating

The inventors have found that loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia can be treated by altering levels of one ormore members of the hedgehog signaling pathway.

Disclosed herein are methods of treating loss and/or distortion of tasteor smell, e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia,dysgeusia, phantogeusia, and/or ageusia in a subject, the methodscomprising increasing and/or maintaining the level of one or moremembers of the hedgehog signaling pathway.

The one or more members of the hedgehog signaling pathway can beselected from a group consisting of: SHH, DHH, and IHH. The one or moremembers of the hedgehog signaling pathway can be SHH, DHH, IHH, or anycombination thereof.

The one or more members of the hedgehog signaling pathway can beincreased and/or maintained by increasing cGMP levels. The increasingand/or maintaining the level of one or more members of the hedgehogsignaling pathway can comprise giving the subject one or more cGMPactivators. The one or more cGMP activators can be given in combinationwith one or more additional therapeutic agents. The cGMP activator canbe riociguat. The one or more additional therapeutic agents can compriseone or more non-selective PDE inhibitors and/or forskolin, orcombinations thereof. The one or more additional therapeutic agents cancomprise one or more selective PDE inhibitors and/or forskolin, orcombinations thereof.

The methods can further comprise administering to the subject one ormore additional therapeutic agents, wherein the one or more additionaltherapeutic agents can comprise riociguat given or present in an amountselected from a group consisting of: greater than 0.0 μg to 1 μg, 0.5 μgto 2 μg, 1.5 μg to 3.0 μg, 2.5 μg to 10 μg, 5 μg to 15 μg, 12.5 μg to 30μg, 25 μg to 50 μg, 40 μg to 80 μg, 60 μg to 100 μg, 90 μg to 120 μg,110 μg to 130 μg, 125 μg to 150 μg, 140 μg to 180 μg, 170 μg to 200 μg,200 μg to 230 μg, 215 μg to 240 μg, 235 μg to less than 250 μg, and lessthan 250 μg, and greater than about 0.0 μg to about 1 μg, about 0.5 μgto about 2 μg, about 1.5 μg to about 3.0 μg, about 2.5 μg to about 10μg, about 5 μg to about 15 μg, about 12.5 μg to about 30 μg, about 25 μgto about 50 μg, about 40 μg to about 80 μg, about 60 μg to about 100 μg,about 90 μg to about 120 μg, about 110 μg to about 130 μg, about 125 μgto about 150 μg, about 140 μg to about 180 μg, about 170 μg to about 200μg, about 200 μg to about 230 μg, about 215 μg to about 240 μg, andabout 235 μg to less than 250 μg.

The methods can further comprise administering to the subject one ormore additional therapeutic agents, wherein the one or more additionaltherapeutic agents can comprise theophylline given or present in anamount selected from a group consisting of: less than 45 mg, 30 mg, 15mg, 10 mg, 5 mg, 1 mg, 500 μg, 250 μg, 120 μg, 80 μg, 40 μg, or 20 μgand less than about 45 mg, about 30 mg, about 15 mg, about 10 mg, about5 mg, about 1 mg, about 500 μg, about 250 μg, about 120 μg, about 80 μg,about 40 μg, or about 20 μg.

The methods can further comprise administering to the subject one ormore additional therapeutic agents, wherein the one or more additionaltherapeutic agents can comprise forskolin given or present in an amountselected from a group consisting of: less than 500 mg to 450 mg, 475 mgto 425 mg, 435 mg to 400 mg, 415 mg to 300 mg, 325 mg to 250 mg, 275 mgto 150 mg, 200 mg to 100 mg, 135 mg to 80 mg, 95 mg to 65 mg, 75 mg to50 mg, 60 mg to 40 mg, 45 mg to 25 mg, 30 mg to 20 mg, 15 mg to 5 mg, 10mg to 2.5 mg, 3.5 mg to 1 mg, and 2 mg to greater than 0 mg, and lessthan about 500 mg to about 450 mg, about 475 mg to about 425 mg, about435 mg to about 400 mg, about 415 mg to about 300 mg, about 325 mg toabout 250 mg, about 275 mg to about 150 mg, about 200 mg to about 100mg, about 135 mg to about 80 mg, about 95 mg to about 65 mg, about 75 mgto about 50 mg, about 60 mg to about 40 mg, about 45 mg to about 25 mg,about 30 mg to about 20 mg, about 15 mg to about 5 mg, about 10 mg toabout 2.5 mg, about 3.5 mg to about 1 mg, and about 2 mg to greater than0 mg.

Any combination of riociguat, theophylline, and/or forskolin can begiven to a subject to raise the level of one or more members of thehedgehog signaling pathway. In certain cases, a particular combinationof riociguat, theophylline, and/or forskolin can exhibit synergisticeffects compared to when treating with riociguat, theophylline, and/orforskolin alone. In other cases, a particular combination of riociguat,theophylline, and/or forskolin can exhibit synergistic effects comparedto when treating with riociguat, theophylline, and/or forskolin inpairs. The methods can further comprise administering to the subject oneor more additional therapeutic agents, wherein the one or moreadditional therapeutic agents can comprise: (a) riociguat given orpresent in an amount selected from a group consisting of: greater than0.0 μg to 1 μg, 0.5 μg to 2 μg, 1.5 μg to 3.0 μg, 2.5 μg to 10 μg, 5 μgto 15 μg, 12.5 μg to 30 μg, 25 μg to 50 μg, 40 μg to 80 μg, 60 μg to 100μg, 90 μg to 120 μg, 110 μg to 130 μg, 125 μg to 150 μg, 140 μg to 180μg, 170 μg to 200 μg, 200 μg to 230 μg, 215 μg to 240 μg, 235 μg to lessthan 250 μg, and less than 250 μg, and greater than about 0.0 μg toabout 1 μg, about 0.5 μg to about 2 μg, about 1.5 μg to about 3.0 μg,about 2.5 μg to about 10 μg, about 5 μg to about 15 μg, about 12.5 μg toabout 30 μg, about 25 μg to about 50 μg, about 40 μg to about 80 μg,about 60 μg to about 100 μg, about 90 μg to about 120 μg, about 110 μgto about 130 μg, about 125 μg to about 150 μg, about 140 μg to about 180μg, about 170 μg to about 200 μg, about 200 μg to about 230 μg, about215 μg to about 240 μg, and about 235 μg to less than 250 μg; (b)theophylline given or present in an amount selected from a groupconsisting of: less than 45 mg, 30 mg, 15 mg, 10 mg, 5 mg, 1 mg, 500 μg,250 μg, 120 μg, 80 μg, 40 μg, or 20 μg and less than about 45 mg, about30 mg, about 15 mg, about 10 mg, about 5 mg, about 1 mg, about 500 μg,about 250 μg, about 120 μg, about 80 μg, about 40 μg, or about 20 μg;and (c) forskolin given or present in an amount selected from a groupconsisting of: less than 500 mg to 450 mg, 475 mg to 425 mg, 435 mg to400 mg, 415 mg to 300 mg, 325 mg to 250 mg, 275 mg to 150 mg, 200 mg to100 mg, 135 mg to 80 mg, 95 mg to 65 mg, 75 mg to 50 mg, 60 mg to 40 mg,45 mg to 25 mg, 30 mg to 20 mg, 15 mg to 5 mg, 10 mg to 2.5 mg, 3.5 mgto 1 mg, and 2 mg to greater than 0 mg, and less than about 500 mg toabout 450 mg, about 475 mg to about 425 mg, about 435 mg to about 400mg, about 415 mg to about 300 mg, about 325 mg to about 250 mg, about275 mg to about 150 mg, about 200 mg to about 100 mg, about 135 mg toabout 80 mg, about 95 mg to about 65 mg, about 75 mg to about 50 mg,about 60 mg to about 40 mg, about 45 mg to about 25 mg, about 30 mg toabout 20 mg, about 15 mg to about 5 mg, about 10 mg to about 2.5 mg,about 3.5 mg to about 1 mg, and about 2 mg to greater than 0 mg.

The methods can further comprise comprising one or more non-selectivePDE inhibitors wherein the one or more non-selective PDE inhibitors cancomprise theophylline. The methods can also further comprise one or morenon-selective PDE inhibitors, wherein the one or more selective PDEinhibitors can be selected from a group consisting of: a PDE-1 selectiveinhibitor, a PDE-2 selective inhibitor, a PDE-3 selective inhibitor, aPDE-4 selective inhibitor, a PDE-5 selective inhibitor, or anycombination thereof.

The maintaining and/or increasing the level of one or more members ofthe hedgehog signaling pathway can comprise administration of aneffective amount of one or more members of the hedgehog signalingpathway. The maintaining and/or increasing the level of one or moremembers of the hedgehog signaling pathway can also compriseadministration of an effective amount of the one or more exogenousmembers of the hedgehog signaling pathway. The maintaining and/orincreasing the level of one or more members of the hedgehog signalingpathway can also comprise activating expression of an effective amountof one or more members of the hedgehog signaling pathway. The activatingexpression of an effective amount of one or more members of the hedgehogsignaling pathway can be effectuated by genetic manipulation of one ormore genes responsible for the expression of one or more members of thehedgehog signaling pathway. The activating expression of an effectiveamount of one or more members of the hedgehog signaling pathway can alsobe effectuated through a therapeutic agent. The therapeutic agent candirectly affect the levels of one or more members of the hedgehogsignaling pathway. The therapeutic agent can indirectly affect thelevels of one or more members of the hedgehog signaling pathway.

The one or more therapeutic agents or composition comprising one or moretherapeutic agents can be suitable for administration by a methodsselected from a group consisting of: oral administration, transmucosaladministration, buccal administration, inhalation administration,intranasal administration, parental administration, intravenousadministration, subcutaneous administration, intramuscularadministration, sublingual administration, transdermal administration,and rectal administration. Because of the ease of use, the one or moretherapeutic agents or composition comprising one or more therapeuticagents can be suitable for oral administration, inhalationaladministration, intranasal administration, or any combination thereof.

The inventors have found that loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia can be effectively ameliorated byincreasing the levels of one or more members of the hedgehog signalingpathway while effecting levels of nitric oxide (NO), TNF alpha (TNF-α),TNF-related apoptosis-inducing ligand (TRAIL), interleukin-1 (IL-1),interleukin-1 receptor antagonist (IL-1RA), and/or interleukin-10(IL-10). In some cases, the combination can lead to synergistic effects.

Disclosed herein are also methods of treating loss and/or distortion oftaste or smell, e.g., hyposmia, dysosmia, anosmia, phantosmia,hypogeusia, dysgeusia, phantogeusia, and/or ageusia in a subject in needthereof, the methods comprising administering to the subject one or moretherapeutic agents or a composition comprising one or more therapeuticagents sufficient to effectuate: (a) maintenance and/or increase in oneor more members of the hedgehog signaling pathway; (b) at least one ormore of the following: (i) an increase in nitric oxide (NO); (ii) adecrease in TNF alpha (TNF-α); (iii) a decrease in TNF-relatedapoptosis-inducing ligand (TRAIL); (iv) a decrease in interleukin-1(IL-1); (v) a decrease in interleukin-1 receptor antagonist (IL-1RA);and (vi) an increase of interleukin-10 (IL-10); and (c) stem celldifferentiation.

The one or more therapeutic agents can comprise one or more cGMPactivators, one or more cAMP activators, or any combination thereof.

The methods can further comprise one or more cGMP activators, whereinthe one or more cGMP activators can be selected from a group consistingof 3-(5′-hydroxymethyl-2′-furyl)-1-benzylindazole (YC-1), YC-1derivatives, anthranilic acids derivatives, ataciguat (HMR1766),benzydamine analogs, CFM1517, A-350619, nitrovasodilators, molsidomine,nitroxyl (HNO), BAY 41-2272, BAY 41-8543, BAY 58-2667, cinaciguat (BAY58-2667), and riociguat (BAY 63-2521). The one or more cGMP activatorscan be riociguat.

The methods can further comprise one or more cAMP activators wherein theone or more cAMP activators can be selected from a group consisting of3-(5′-hydroxymethyl-2′-furyl)-1-benzylindazole (YC-1), glucagon, PDEinhibitors, prostaglandin E1 (PGE1; pharmaceutically known asalprostadil), forskolin, and β-adrenergic agonists. The methods canfurther comprise one or more cAMP activators wherein the one or morecAMP activators can comprise one or more PDE inhibitors and/orforskolin. The methods can further comprise one or more cAMP activatorswherein the one or more cAMP activators can be forskolin.

The methods can further comprise one or more cAMP activators wherein theone or more cAMP activators can be one or more PDE inhibitors. The oneor more PDE inhibitors can comprise a non-selective PDE inhibitor, aPDE-1 selective inhibitor, a PDE-2 selective inhibitor, a PDE-3selective inhibitor, a PDE-4 selective inhibitor, a PDE-5 selectiveinhibitor, a PDE-10 selective inhibitor, or any combination thereof. Theone or more PDE inhibitors can be a selective PDE inhibitor. The one ormore PDE inhibitors can comprise a non-selective PDE inhibitor that canbe a methylxanthine derivative. The methylxanthine derivative can becaffeine, theophylline, doxophylline, cipamphylline, neuphylline,pentoxiphylline, or diprophylline. The methylxanthine derivative can betheophylline. The PDE 1 inhibitor can be vinpocetine, compound KS505a,bepril, flunarizine, amiodarone, zaprinast, 8-methoxymethyl IPMX, SCH51866, Nimodipine, or IC224. The PDE 2 inhibitor that can be EHNA. ThePDE 3 inhibitor can be enoximone, milrinone (Primacor), amrinone,cilostamide, cilostazol (Pletal), trequinsin, inamrinone, anagrelide,pimobendan, lixazinone, or dihydro-pyridazinone. The PDE 4 inhibitor canbe mesembrine, rolipram, ibudilast, roflumilast (Daxas), cilomilast(Airflo), piclamilast, luteolin, drotaverine, or denbufylline. The PDE 5inhibitor can be sildenafil, tadalafil, vardenafil, udenafil andavanafil, dipyridamole, icariin, 4-Methylpiperazine, PyrazoloPyrimidin-7-1, cilomilast, or zaprinast. The PDE6-selective inhibitorscan be zaprinast, dipyridamole, vardenafil, or tadalafil. ThePDE7-selective inhibitors can be quinazoline type PDE7 inhibitor,dipyridamole, or thiadiazole. The PDE8-selective inhibitors can bedipyridamole. The PDE9-selective inhibitors can be zaprinast. The PDE 10inhibitor can be papaverine, OMS824 (from Omeros Corporation), and/orPF-2545920 (from Pfizer). The PDE11-selective inhibitors can betadalafil, zaprinast, or dipyridamole.

The one or more therapeutic agents can comprise a non-selective PDEinhibitor, forskolin, and riociguat. The one or more therapeutic agentscan comprise a selective PDE inhibitor, forskolin, and riociguat.Various combinations are also contemplated. For example, the one or moretherapeutic agents can comprise a non-selective PDE inhibitor,theophylline, and riociguat. The one or more therapeutic agents cancomprise a selective PDE inhibitor, theophylline, and riociguat. The oneor more therapeutic agents can comprise a non-selective PDE inhibitorand riociguat. The one or more therapeutic agents can comprise aselective PDE inhibitor and riociguat. The one or more therapeuticagents can comprise theophylline and riociguat. The one or moretherapeutic agents can comprise forskolin and riociguat. The one or moretherapeutic agents can comprise theophylline, forskolin, and riociguat.

The methods of this invention can comprise one or more therapeuticagents, wherein the one or more therapeutic agents can be steroid-free.

Riociguat can be given and/or present in an amount selected from a groupconsisting of: greater than 0.0 μg to 1 μg, 0.5 μg to 2 μg, 1.5 μg to3.0 μg, 2.5 μg to 10 μg, 5 μg to 15 μg, 12.5 μg to 30 μg, 25 μg to 50μg, 40 μg to 80 μg, 60 μg to 100 μg, 90 μg to 120 μg, 110 μg to 130 μg,125 μg to 150 μg, 140 μg to 180 μg, 170 μg to 200 μg, 200 μg to 230 μg,215 μg to 240 μg, 235 μg to less than 250 μg, less than 250 μg andgreater than about 0.0 μg to about 1 μg, about 0.5 μg to about 2 μg,about 1.5 μg to about 3.0 μg, about 2.5 μg to about 10 μg, about 5 μg toabout 15 μg, about 12.5 μg to about 30 μg, about 25 μg to about 50 μg,about 40 μg to about 80 μg, about 60 μg to about 100 μg, about 90 μg toabout 120 μg, about 110 μg to about 130 μg, about 125 μg to about 150μg, about 140 μg to about 180 μg, about 170 μg to about 200 μg, about200 μg to about 230 μg, about 215 μg to about 240 μg, about 235 μg toless than about 250 μg.

Theophylline can be given and/or present in an amount selected from agroup consisting of: less than 45 mg, 30 mg, 15 mg, 10 mg, 5 mg, 1 mg,500 μg, 250 μg, 120 μg, 80 μg, 40 μg, or 20 μg and less than about 45mg, about 30 mg, about 15 mg, about 10 mg, about 5 mg, about 1 mg, about500 μg, about 250 μg, about 120 μg, about 80 μg, about 40 μg, or about20 μg.

Forskolin can be given and/or present in an amount selected from a groupconsisting of: less than 500 mg to 450 mg, 475 mg to 425 mg, 435 mg to400 mg, 415 mg to 300 mg, 325 mg to 250 mg, 275 mg to 150 mg, 200 mg to100 mg, 135 mg to 80 mg, 95 mg to 65 mg, 75 mg to 50 mg, 60 mg to 40 mg,45 mg to 25 mg, 30 mg to 20 mg, 15 mg to 5 mg, 10 mg to 2.5 mg, 3.5 mgto 1 mg, 2 mg to greater than 0 mg and less than about 500 mg to about450 mg, about 475 mg to about 425 mg, about 435 mg to about 400 mg,about 415 mg to about 300 mg, about 325 mg to about 250 mg, about 275 mgto about 150 mg, about 200 mg to about 100 mg, about 135 mg to about 80mg, about 95 mg to about 65 mg, about 75 mg to about 50 mg, about 60 mgto about 40 mg, about 45 mg to about 25 mg, about 30 mg to about 20 mg,about 15 mg to about 5 mg, about 10 mg to about 2.5 mg, about 3.5 mg toabout 1 mg, about 2 mg to greater than about 0 mg.

Any combination of riociguat, theophylline, and/or forskolin can begiven to a subject to raise the level of one or more members of thehedgehog signaling pathway and/or NO, TNF-α, TRAIL, IL-1, IL-1RA, and/orIL-10. In certain cases, a particular combination of riociguat,theophylline, and/or forskolin can exhibit synergistic effects comparedto when treating with riociguat, theophylline, and/or forskolin alone.In other cases, a particular combination of riociguat, theophylline,and/or forskolin can exhibit synergistic effects compared to whentreating with riociguat, theophylline, and/or forskolin in pairs. Themethods can comprise methods wherein (a) riociguat can be given and/orpresent in an amount selected from a group consisting of: greater than0.0 μg to 1 μg, 0.5 μg to 2 μg, 1.5 μg to 3.0 μg, 2.5 μg to 10 μg, 5 μgto 15 μg, 12.5 μg to 30 μg, 25 μg to 50 μg, 40 μg to 80 μg, 60 μg to 100μg, 90 μg to 120 μg, 110 μg to 130 μg, 125 μg to 150 μg, 140 μg to 180μg, 170 μg to 200 μg, 200 μg to 230 μg, 215 μg to 240 μg, 235 μg to lessthan 250 μg, and less than 250 μg, and greater than about 0.0 μg toabout 1 μg, about 0.5 μg to about 2 μg, about 1.5 μg to about 3.0 μg,about 2.5 μg to about 10 μg, about 5 μg to about 15 μg, about 12.5 μg toabout 30 μg, about 25 μg to about 50 μg, about 40 μg to about 80 μg,about 60 μg to about 100 μg, about 90 μg to about 120 μg, about 110 μgto about 130 μg, about 125 μg to about 150 μg, about 140 μg to about 180μg, about 170 μg to about 200 μg, about 200 μg to about 230 μg, about215 μg to about 240 μg, and about 235 μg to less than 250 gig; (b)theophylline can be given and/or present in an amount selected from agroup consisting of: less than 45 mg, 30 mg, 15 mg, 10 mg, 5 mg, 1 mg,500 μg, 250 μg, 120 μg, 80 μg, 40 μg, or 20 μg and less than about 45mg, about 30 mg, about 15 mg, about 10 mg, about 5 mg, about 1 mg, about500 μg, about 250 μg, about 120 μg, about 80 μg, about 40 μg, or about20 μg; and (c) forskolin can be given and/or present in an amountselected from a group consisting of: less than 500 mg to 450 mg, 475 mgto 425 mg, 435 mg to 400 mg, 415 mg to 300 mg, 325 mg to 250 mg, 275 mgto 150 mg, 200 mg to 100 mg, 135 mg to 80 mg, 95 mg to 65 mg, 75 mg to50 mg, 60 mg to 40 mg, 45 mg to 25 mg, 30 mg to 20 mg, 15 mg to 5 mg, 10mg to 2.5 mg, 3.5 mg to 1 mg, and 2 mg to greater than 0 mg, and lessthan about 500 mg to about 450 mg, about 475 mg to about 425 mg, about435 mg to about 400 mg, about 415 mg to about 300 mg, about 325 mg toabout 250 mg, about 275 mg to about 150 mg, about 200 mg to about 100mg, about 135 mg to about 80 mg, about 95 mg to about 65 mg, about 75 mgto about 50 mg, about 60 mg to about 40 mg, about 45 mg to about 25 mg,about 30 mg to about 20 mg, about 15 mg to about 5 mg, about 10 mg toabout 2.5 mg, about 3.5 mg to about 1 mg, and about 2 mg to greater than0 mg.

The increasing and/or maintaining the level of one or more members ofthe hedgehog signaling pathway can comprise administering an effectiveamount of one or more members of the hedgehog signaling pathway. Theincreasing and/or maintaining the level of one or more members of thehedgehog signaling pathway can comprise administering an effectiveamount of one or more exogenous members of the hedgehog signalingpathway. The increasing and/or maintaining the level of one or moremembers of the hedgehog signaling pathway can comprise activatingexpression of an effective amount of one or more members of the hedgehogsignaling pathway. The activating expression of an effective amount ofone or more members of the hedgehog signaling pathway can be effectuatedby genetic manipulation of one or more genes responsible for theexpression of one or more members of the hedgehog signaling pathway. Theactivating expression of an effective amount of one or more members ofthe hedgehog signaling pathway can be effectuated through a therapeuticagent. The therapeutic agent can directly affect the levels of one ormore members of the hedgehog signaling pathway. The therapeutic agentcan indirectly affect the levels of one or more members of the hedgehogsignaling pathway.

The one or more therapeutic agents or composition comprising one or moretherapeutic agents can be suitable for administration by a methodselected from a group consisting of: oral administration, transmucosaladministration, buccal administration, inhalation administration,intranasal administration, parental administration, intravenousadministration, subcutaneous administration, intramuscularadministration, sublingual administration, transdermal administration,and rectal administration. Because of ease of use, the one or moretherapeutic agents or composition comprising one or more therapeuticagents can be suitable for oral administration, inhalationaladministration, intranasal administration, or any combination thereof.

The one or more therapeutic agents or compositions can show anunexpected efficacy when formulated as a liquid above a specific pH.Sometimes, any combination of one or more therapeutic agents whenformulated above a specific pH can result in synergistic effects. Theone or more therapeutic agents or composition comprising one or moretherapeutic agents can be a liquid. The one or more therapeutic agentsor composition comprising one or more therapeutic agents can have a pHof greater than 7.0. The one or more therapeutic agents or compositioncomprising one or more therapeutic agents can have a pH of greater than7.1. The one or more therapeutic agents or composition comprising one ormore therapeutic agents can have a pH of greater than 7.5. The one ormore therapeutic agents or composition comprising one or moretherapeutic agents can have a pH of greater than 8.0. The one or moretherapeutic agents or composition comprising one or more therapeuticagents can have a pH of greater than 9.0.

Excipients can be added to one or more therapeutic agents orcompositions. The excipients that can be used in the invention caninclude those found in the Handbook of Pharmaceutical Excipients, SixthEdition (2009), Eds. R. C. Rowe, P. J. Shesky, and M. E. Quinn,incorporated herein by reference in its entirety. For example, it iscontemplated that the following excipients can be added separately or inany combination, to one or more therapeutic agents or composition:Acacia, Acesulfame Potassium, Acetic Acid—Glacial, Acetone,Acetyltributyl Citrate, Acetyltriethyl Citrate, Adipic Acid, Agar,Albumin, Alcohol, Alginic Acid, Aliphatic Polyesters, Alitame, AlmondOil, Alpha Tocopherol, Aluminum Hydroxide Adjuvant, AluminumMonostearate, Aluminum Oxide, Aluminum Phosphate Adjuvant, AmmoniaSolution, Ammonium Alginate, Ammonium Chloride, Ascorbic Acid, AscorbylPalmitate, Aspartame, Attapulgite, Bentonite, Benzalkonium Chloride,Benzethonium Chloride, Benzoic Acid, Benzyl Alcohol, Benzyl Benzoate,Boric Acid, Bronopol, Butylated Hydroxyanisole, ButylatedHydroxytoluene, Butylene Glycol, Butylparaben, Calcium Acetate, CalciumAlginate, Calcium Carbonate, Calcium Chloride, Calcium Hydroxide,Calcium Lactate, Calcium Phosphate—Dibasic Anhydrous, CalciumPhosphate—Dibasic Dihydrate, Calcium Phosphate—Tribasic, CalciumSilicate, Calcium Stearate, Calcium Sulfate, Canola Oil, Carbomer,Carbon Dioxide, Carboxymethylcellulose Calcium, CarboxymethylcelluloseSodium, Carrageenan, Castor Oil, Castor Oil—Hydrogenated,Cellulose—Microcrystalline, Cellulose—Microcrystalline andCarboxymethylcellulose Sodium, Cellulose—Powdered, Cellulose—SilicifiedMicrocrystalline, Cellulose Acetate, Cellulose Acetate Phthalate,Ceratonia, Ceresin, Cetostearyl Alcohol, Cetrimide, Cetyl Alcohol,Cetylpyridinium Chloride, Chitosan, Chlorhexidine, Chlorobutanol,Chlorocresol, Chlorodifluoroethane (HCFC), Chlorofluorocarbons (CFC),Chloroxylenol, Cholesterol, Citric Acid Monohydrate, Coconut Oil,Colloidal Silicon Dioxide, Coloring Agents, Copovidone, Corn Oil, CornStarchand Pregelatinized Starch, Cottonseed Oil, Cresol, CroscarmelloseSodium, Crospovidone, Cyclodextrins, Cyclomethicone, DenatoniumBenzoate, Dextrates, Dextrin, Dextrose, Dibutyl Phthalate, DibutylSebacate, Diethanolamine, Diethyl Phthalate, Difluoroethane (HFC),Dimethicone, Dimethyl Ether, Dimethyl Phthalate, Dimethyl Sulfoxide,Dimethylacetamide, Disodium Edetate, Docusate Sodium, Edetic Acid,Erythorbic Acid, Erythritol, Ethyl Acetate, Ethyl Lactate, Ethyl Maltol,Ethyl Oleate, Ethyl Vanillin, Ethylcellulose, Ethylene Glycol Stearates,Ethylene Vinyl Acetate, Ethylparaben, Fructose, Fumaric Acid, Gelatin,Glucose—Liquid, Glycerin, Glyceryl Behenate, Glyceryl Monooleate,Glyceryl Monostearate, Glyceryl Palmitostearate, Glycine, Glycofurol,Guar Gum, Hectorite, Heptafluoropropane (HFC), Hexetidine, Hydrocarbons(HC), Hydrochloric Acid, Hydrophobic Colloidal Silica, HydroxyethylCellulose, Hydroxyethylmethyl Cellulose, Hydroxypropyl Betadex,Hydroxypropyl Cellulose, Hydroxypropyl Cellulose—Low-substituted,Hydroxypropyl Starch, Hypromellose, Hypromellose Acetate Succinate,Hypromellose Phthalate, Imidurea, Inulin, Iron Oxides, Isomalt,Isopropyl Alcohol, Isopropyl Myristate, Isopropyl Palmitate, Kaolin,Lactic Acid, Lactitol, Lactose—Anhydrous, Lactose—Inhalation,Lactose—Monohydrate, Lactose—Monohydrate and Corn Starch,Lactose—Monohydrate and Microcrystalline Cellulose, Lactose—Monohydrateand Povidone, Lactose—Monohydrate and Powdered Cellulose,Lactose—Spray-Dried, Lanolin, Lanolin—Hydrous, Lanolin Alcohols, LaurieAcid, Lecithin, Leucine, Linoleic Acid, Macrogol 15 Hydroxystearate,Magnesium Aluminum Silicate, Magnesium Carbonate, Magnesium Oxide,Magnesium Silicate, Magnesium Stearate, Magnesium Trisilicate, MaleicAcid, Malic Acid, Maltitol, Maltitol Solution, Maltodextrin, Maltol,Maltose, Mannitol, Medium-chain Triglycerides, Meglumine, Menthol,Methionine, Methylcellulose, Methylparaben, Mineral Oil, MineralOil—Light, Mineral Oil and Lanolin Alcohols, Monoethanolamine,Monosodium Glutamate, Monothioglycerol, Myristic Acid, Myristyl Alcohol,Neohesperidin Dihydrochalcone, Neotame, Nitrogen, Nitrous Oxide,Octyldodecanol, Oleic Acid, Oleyl Alcohol, Olive Oil, Palmitic Acid,Paraffin, Peanut Oil, Pectin, Pentetic Acid, Petrolatum, Petrolatum andLanolin Alcohols, Phenol, Phenoxyethanol, Phenylethyl Alcohol,Phenylmercuric Acetate, Phenylmercuric Borate, Phenylmercuric Nitrate,Phospholipids, Phosphoric Acid, Polacrilin Potassium, Poloxamer,Polycarbophil, Polydextrose, Poly (DL-Lactic Acid), Polyethylene Glycol,Polyethylene Oxide, Polymethacrylates, Poly(methyl vinylether/maleicanhydride), Polyoxyethylene Alkyl Ethers, Polyoxyethylene Castor OilDerivatives, Polyoxyethylene Sorbitan Fatty Acid Esters, PolyoxyethyleneStearates, Polyoxylglycerides, Polyvinyl Acetate Phthalate, PolyvinylAlcohol, Potassium Alginate, Potassium Alum, Potassium Benzoate,Potassium Bicarbonate, Potassium Chloride, Potassium Citrate, PotassiumHydroxide, Potassium Metabisulfite, Potassium Sorbate, Povidone,Propionic Acid, Propyl Gallate, Propylene Carbonate, Propylene Glycol,Propylene Glycol Alginate, Propylparaben, Propylparaben Sodium,Pyrrolidone, Raffinose, Saccharin, Saccharin Sodium, Safflower Oil,Saponite, Sesame Oil, Shellac, Simethicone, Sodium Acetate, SodiumAlginate, Sodium Ascorbate, Sodium Benzoate, Sodium Bicarbonate, SodiumBorate, Sodium Carbonate, Sodium Chloride, Sodium Citrate Dihydrate,Sodium Cyclamate, Sodium Formaldehyde Sulfoxylate, Sodium Hyaluronate,Sodium Hydroxide, Sodium Lactate, Sodium Lauryl Sulfate, SodiumMetabisulfite, Sodium Phosphate—Dibasic, Sodium Phosphate—Monobasic,Sodium Propionate, Sodium Starch Glycolate, Sodium Stearyl Fumarate,Sodium Sulfite, Sodium Thiosulfate, Sorbic Acid, Sorbitan Esters(Sorbitan Fatty Acid Esters), Sorbitol, Soybean Oil, Starch,Starch—Pregelatinized, Starch—Sterilizable Maize, Stearic Acid, StearylAlcohol, Sucralose, Sucrose, Sucrose Octaacetate, Sugar—Compressible,Sugar—Confectioner's, Sugar Spheres, Sulfobutylether b-Cyclodextrin,Sulfur Dioxide, Sulfuric Acid, Sunflower Oil, Suppository Bases—HardFat, Tagatose, Talc, Tartaric Acid, Tetrafluoroethane (HFC), Thaumatin,Thimerosal, Thymol, Titanium Dioxide, Tragacanth, Trehalose, Triacetin,Tributyl Citrate, Tricaprylin, Triethanolamine, Triethyl Citrate,Triolein, Vanillin, Vegetable Oil—Hydrogenated, Vitamin E PolyethyleneGlycol Succinate, Water, Wax—Anionic Emulsifying, Wax—Carnauba,Wax—Cetyl Esters, Wax—Microcrystalline, Wax—Nonionic Emulsifying,Wax—White, Wax—Yellow, Xanthan Gum, Xylitol, Zein, Zinc Acetate, and/orZinc Stearate.

The one or more therapeutic agents or composition comprising one or moretherapeutic agents can further comprise one or more excipients. The oneor more therapeutic agents or composition comprising one or moretherapeutic agents can further comprise one or more excipients whereinthe one or more excipients can be selected from a group consisting of:detackifiers, anti-foaming agents, buffering agents, polymers,antioxidants, preservatives, chelating agents, viscomodulators,tonicifiers, flavorants, colorants, odorants, opacifiers, suspendingagents, binders, fillers, plasticizers, lubricants, and mixturesthereof.

The one or more therapeutic agents can comprise one or more cytochromep450 inhibitors. The one or more therapeutic agents or compositioncomprising one or more therapeutic agents can further comprise one ormore cytochrome p450 inhibitors wherein the one or more cytochrome p450inhibitors can fully or partially inhibit a cytochrome p450 selectedfrom a group consisting of: CYP1, CYP1A1, CYP1A2, CYP1B1, CYP2, CYP2A6,CYP2A7, CYP2A13, CYP2B6, CYP2C8, CYP2C9, CYP2C18, CYP2C19, CYP2D6,CYP2E1, CYP2F1, CYP2J2, CYP2R1, CYP2S1, CYP2U1, CYP2W1, CYP3, CYP3A4,CYP3A5, CYP3A7, CYP3A43, CYP4, CYP4A11, CYP4A22, CYP4B1, CYP4F2, CYP4F3,CYP4F8, CYP4F11, CYP4F12, CYP4F22, CYP4V2, CYP4X1, CYP4Z1, CYP5, CYP5A1,CYP7, CYP7A1, CYP7B1, CYP8, CYP8A1, CYP8B1, CYP11, CYP11A1, CYP11B1,CYP11B2, CYP17, CYP17A1, CYP19, CYP19A1, CYP20, CYP20A1, CYP21, CYP21A2,CYP24, CYP24A1, CYP26, CYP26A1, CYP26B1, CYP26C1, CYP27, CYP27A1,CYP27B1, CYP27C1, CYP39, CYP39A1, CYP46, CYP46A1, CYP51, and CYP51A1.The one or more cytochrome p450 inhibitors can fully or partiallyinhibit CYP1. The one or more cytochrome p450 inhibitors can fully orpartially inhibit CYP1A2. The one or more CYP1A2 inhibitor can beselected from a group consisting of: fluoroquinolone, selectiveserotonin reuptake inhibitor (SSRI), calcium channel blocker, herbaltea, naringenin, H2-receptor antagonist, antiarrhythmic agent,interferon, xanthotoxin, mibefradil, cumin, turmeric, and isoniazid. Theone or more CYP1A2 inhibitor can be grapefruit juice. The one or moreCYP1A2 inhibitor can be naringenin.

The one or more therapeutic agents or composition comprising one or moretherapeutic agents can further comprise one or more β-adrenergicagonists. The one or more β-adrenergic agonists can be a β₁-adrenergicagonist and/or β₂-adrenergic agonist. The one or more therapeutic agentsor composition can comprise one or more β-adrenergic agonists whereinthe one or more β-adrenergic agonists can be a β₁-adrenergic agonist.The one or more therapeutic agents or composition can comprise one ormore β-adrenergic agonists wherein the one or more β-adrenergic agonistscan be a β₁-adrenergic agonist selected from a group consisting of:dobutamine, isoproterenol, xamoterol and epinephrine. The one or moretherapeutic agents or composition can comprise one or more β-adrenergicagonists wherein the one or more β-adrenergic agonists can be aβ₂-adrenergic agonist. The one or more therapeutic agents or compositioncan comprise one or more β-adrenergic agonists wherein the one or moreβ-adrenergic agonists can be a β₂-adrenergic agonist selected from agroup consisting of: albuterol, levalbuterol, fenoterol, formoterol,isoproterenol (β₁ and β₂), metaproterenol, salmeterol, terbutaline,clenbuterol, isoetarine, pirbuterol, procaterol, ritodrine, andepinephrine. The one or more therapeutic agents or composition cancomprise one or more β-adrenergic agonists wherein the one or moreβ-adrenergic agonists can be selected from a group consisting of:arbutamine, befunolol, bromoacetylalprenololmenthane, broxaterol,cimaterol, cirazoline, denopamine, dopexamine, etilefrine,hexoprenaline, higenamine, isoxsuprine, mabuterol, methoxyphenamine,nylidrin, oxyfedrine, prenalterol, ractopamine, reproterol, rimiterol,tretoquinol, tulobuterol, zilpaterol, and zinterol.

Drug Compositions for Treatment

The inventors have found that loss and/or distortion of taste or smell,e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia can be effectively ameliorated by using apharmaceutical dosage unit comprising one or more cGMP activator and/orone or more cAMP activator. In some cases, the combination of cGMP andcAMP activators can produce a synergistic effect.

In an additional aspect of the invention, disclosed herein is apharmaceutical dosage unit comprising one or more cGMP activators, oneor more cAMP activators, and any combination thereof.

The pharmaceutical dosage unit can comprise one or more cGMP activatorswherein the one or more cGMP activators can be selected from a groupconsisting of 3-(5′-hydroxymethyl-2′-furyl)-1-benzylindazole (YC-1),YC-1 derivatives, anthranilic acids derivatives, ataciguat (HMR1766),benzydamine analogs, CFM1517, A-350619, nitrovasodilators, molsidomine,nitroxyl (HNO), BAY 41-2272, BAY 41-8543, BAY 58-2667, cinaciguat (BAY58-2667), and riociguat (BAY 63-2521). The pharmaceutical dosage unitcan also comprise one or more cGMP activators wherein the one or morecGMP activators can be riociguat.

The pharmaceutical dosage unit can comprise one or more cAMP activatorswherein the one or more cAMP activators can be selected from a groupconsisting of: 3-(5′-hydroxymethyl-2′-furyl)-1-benzylindazole (YC-1),glucagon, PDE inhibitors, prostaglandin E1 (PGE1; pharmaceutically knownas alprostadil), forskolin, and β-adrenergic agonists. Thepharmaceutical dosage unit can also comprise one or more cAMP activatorswherein the one or more cAMP activators can comprise one or more PDEinhibitors and/or forskolin. The pharmaceutical dosage unit can alsocomprise one or more cAMP activators wherein the one or more cAMPactivators can comprise forskolin.

The pharmaceutical dosage unit can further comprise one or more PDEinhibitors. The one or more PDE inhibitors can comprise a non-selectivePDE inhibitor, a PDE-1 selective inhibitor, a PDE-2 selective inhibitor,a PDE-3 selective inhibitor, a PDE-4 selective inhibitor, a PDE-5selective inhibitor, a PDE-10 selective inhibitor, or any combinationthereof. The one or more PDE inhibitors can comprise a selective PDEinhibitor. The one or more PDE inhibitor can be a non-selective PDEinhibitor that can be a methylxanthine derivative. The methylxanthinederivative can be caffeine, theophylline, doxophylline, cipamphylline,neuphylline, pentoxiphylline, or diprophylline. The methylxanthinederivative can be theophylline. The PDE 1 inhibitor can be vinpocetine,compound KS505a, bepril, flunarizine, amiodarone, zaprinast,8-methoxymethyl IPMX, SCH 51866, Nimodipine, or IC224. The PDE 2inhibitor can be EHNA. The PDE 3 inhibitor can be enoximone, milrinone(Primacor), amrinone, cilostamide, cilostazol (Pletal), trequinsin,inamrinone, anagrelide, pimobendan, lixazinone, or dihydro-pyridazinone.The PDE 4 inhibitor can be mesembrine, rolipram, ibudilast, roflumilast(Daxas), cilomilast (Airflo), piclamilast, luteolin, drotaverine, ordenbufylline. The PDE 5 inhibitor can be sildenafil, tadalafil,vardenafil, udenafil and avanafil, dipyridamole, icariin,4-Methylpiperazine, Pyrazolo Pyrimidin-7-1, cilomilast, or zaprinast.The PDE6-selective inhibitors can be zaprinast, dipyridamole,vardenafil, or tadalafil. The PDE7-selective inhibitors can bequinazoline type PDE7 inhibitor, dipyridamole, or thiadiazole. ThePDE8-selective inhibitors can be dipyridamole. The PDE9-selectiveinhibitors can be zaprinast. The PDE 10 inhibitor can be papaverine,OMS824 (from Omeros Corporation), and/or PF-2545920 (from Pfizer). ThePDE11-selective inhibitors can be tadalafil, zaprinast, or dipyridamole.

The pharmaceutical dosage unit can comprise a non-selective PDEinhibitor, forskolin, and riociguat. The dosage unit can comprise aselective PDE inhibitor, forskolin, and riociguat. Various combinationcan be used. For example, the dosage unit can comprise a non-selectivePDE inhibitor, theophylline, and riociguat. The dosage unit can comprisea selective PDE inhibitor, theophylline, and riociguat. The dosage unitcan comprise a non-selective PDE inhibitor and riociguat. The dosageunit can comprise a selective PDE inhibitor and riociguat. The dosageunit can comprise theophylline, forskolin, and riociguat. The dosageunit can comprise theophylline and riociguat. The dosage unit cancomprise forskolin and riociguat. The dosage unit can compriseriociguat.

The invention can include a dosage unit, wherein the dosage unit can besteroid-free.

Riociguat can be given and/or present in an amount selected from a groupconsisting of: greater than 0.0 μg to 1 μg, 0.5 μg to 2 μg, 1.5 μg to3.0 μg, 2.5 μg to 10 μg, 5 μg to 15 μg, 12.5 μg to 30 μg, 25 μg to 50μg, 40 μg to 80 μg, 60 μg to 100 μg, 90 μg to 120 μg, 110 μg to 130 μg,125 μg to 150 μg, 140 μg to 180 μg, 170 μg to 200 μg, 200 μg to 230 μg,215 μg to 240 μg, 235 μg to less than 250 μg, less than 250 μg andgreater than about 0.0 μg to about 1 μg, about 0.5 μg to about 2 μg,about 1.5 μg to about 3.0 μg, about 2.5 μg to about 10 μg, about 5 μg toabout 15 μg, about 12.5 μg to about 30 μg, about 25 μg to about 50 μg,about 40 μg to about 80 μg, about 60 μg to about 100 μg, about 90 μg toabout 120 μg, about 110 μg to about 130 μg, about 125 μg to about 150μg, about 140 μg to about 180 μg, about 170 μg to about 200 μg, about200 μg to about 230 μg, about 215 μg to about 240 μg, about 235 μg toless than about 250 μg.

Theophylline can be given and/or present in an amount selected from agroup consisting of: less than 45 mg, 30 mg, 15 mg, 10 mg, 5 mg, 1 mg,500 μg, 250 μg, 120 μg, 80 μg, 40 μg, or 20 μg and less than about 45mg, about 30 mg, about 15 mg, about 10 mg, about 5 mg, about 1 mg, about500 μg, about 250 μg, about 120 μg, about 80 μg, about 40 μg, or about20 μg.

Forskolin can be given and/or present in an amount selected from a groupconsisting of: less than 500 mg to 450 mg, 475 mg to 425 mg, 435 mg to400 mg, 415 mg to 300 mg, 325 mg to 250 mg, 275 mg to 150 mg, 200 mg to100 mg, 135 mg to 80 mg, 95 mg to 65 mg, 75 mg to 50 mg, 60 mg to 40 mg,45 mg to 25 mg, 30 mg to 20 mg, 15 mg to 5 mg, 10 mg to 2.5 mg, 3.5 mgto 1 mg, 2 mg to greater than 0 mg and less than about 500 mg to about450 mg, about 475 mg to about 425 mg, about 435 mg to about 400 mg,about 415 mg to about 300 mg, about 325 mg to about 250 mg, about 275 mgto about 150 mg, about 200 mg to about 100 mg, about 135 mg to about 80mg, about 95 mg to about 65 mg, about 75 mg to about 50 mg, about 60 mgto about 40 mg, about 45 mg to about 25 mg, about 30 mg to about 20 mg,about 15 mg to about 5 mg, about 10 mg to about 2.5 mg, about 3.5 mg toabout 1 mg, about 2 mg to greater than about 0 mg.

It is contemplated that riociguat, theophylline, and/or forskolin can becombined. In certain cases, a particular combination of riociguat,theophylline, and/or forskolin can exhibit synergistic effects, comparedto compositions with riociguat, theophylline, and/or forskolin alone. Inother cases, a particular combination of riociguat, theophylline, and/orforskolin can exhibit synergistic effects compared to compositions withriociguat, theophylline, and/or forskolin in pairs. The pharmaceuticaldosage unit can be a dosage unit wherein (a) riociguat can be givenand/or present in an amount selected from a group consisting of: greaterthan 0.0 μg to 1 μg, 0.5 μg to 2 μg, 1.5 μg to 3.0 μg, 2.5 μg to 10 μg,5 μg to 15 μg, 12.5 μg to 30 μg, 25 μg to 50 μg, 40 μg to 80 μg, 60 μgto 100 μg, 90 μg to 120 μg, 110 μg to 130 μg, 125 μg to 150 μg, 140 μgto 180 μg, 170 μg to 200 μg, 200 μg to 230 μg, 215 μg to 240 μg, 235 μgto less than 250 μg, and less than 250 μg, and greater than about 0.0 μgto about 1 μg, about 0.5 μg to about 2 μg, about 1.5 μg to about 3.0 μg,about 2.5 μg to about 10 μg, about 5 μg to about 15 μg, about 12.5 μg toabout 30 μg, about 25 μg to about 50 μg, about 40 μg to about 80 μg,about 60 μg to about 100 μg, about 90 μg to about 120 μg, about 110 μgto about 130 μg, about 125 μg to about 150 μg, about 140 μg to about 180μg, about 170 μg to about 200 μg, about 200 μg to about 230 μg, about215 μg to about 240 μg, and about 235 μg to less than 250 μg; (b)theophylline can be given and/or present in an amount selected from agroup consisting of: less than 45 mg, 30 mg, 15 mg, 10 mg, 5 mg, 1 mg,500 μg, 250 μg, 120 μg, 80 μg, 40 μg, or 20 μg and less than about 45mg, about 30 mg, about 15 mg, about 10 mg, about 5 mg, about 1 mg, about500 μg, about 250 μg, about 120 μg, about 80 μg, about 40 μg, or about20 μg; and (c) forskolin can be given and/or present in an amountselected from a group consisting of: less than 500 mg to 450 mg, 475 mgto 425 mg, 435 mg to 400 mg, 415 mg to 300 mg, 325 mg to 250 mg, 275 mgto 150 mg, 200 mg to 100 mg, 135 mg to 80 mg, 95 mg to 65 mg, 75 mg to50 mg, 60 mg to 40 mg, 45 mg to 25 mg, 30 mg to 20 mg, 15 mg to 5 mg, 10mg to 2.5 mg, 3.5 mg to 1 mg, and 2 mg to greater than 0 mg, and lessthan about 500 mg to about 450 mg, about 475 mg to about 425 mg, about435 mg to about 400 mg, about 415 mg to about 300 mg, about 325 mg toabout 250 mg, about 275 mg to about 150 mg, about 200 mg to about 100mg, about 135 mg to about 80 mg, about 95 mg to about 65 mg, about 75 mgto about 50 mg, about 60 mg to about 40 mg, about 45 mg to about 25 mg,about 30 mg to about 20 mg, about 15 mg to about 5 mg, about 10 mg toabout 2.5 mg, about 3.5 mg to about 1 mg, and about 2 mg to greater than0 mg.

The dosage unit or composition comprising the dosage unit can besuitable for administration by a method selected from a group consistingof: oral administration, transmucosal administration, buccaladministration, inhalation administration, intranasal administration,parental administration, intravenous administration, subcutaneousadministration, intramuscular administration, sublingual administration,transdermal administration, and rectal administration. For ease of use,the dosage unit or composition comprising the dosage unit can besuitable for oral administration, inhalational administration,intranasal administration, or any combination thereof. The dosage unitor composition comprising the dosage unit can also be a liquid.

The dosage unit or composition can be affected by pH. The dosage unitcan exhibit synergistic effects when the pH is above a particularthreshold. For example, the dosage unit or composition can have a pH ofgreater than 7.0. The dosage unit or composition can have a pH ofgreater than 7.1. The dosage unit or composition can have a pH ofgreater than 7.5. The dosage unit or composition can have a pH ofgreater than 8.0. The dosage unit or composition can have a pH ofgreater than 9.0.

Excipients can be added to one or more therapeutic agents orcompositions. The excipients that can be used in the invention caninclude those found in the Handbook of Pharmaceutical Excipients, SixthEdition (2009), Eds. R. C. Rowe, P. J. Shesky, and M. E. Quinn,incorporated herein by reference in its entirety. For example, it iscontemplated that the following excipients can be added separately or inany combination, to one or more therapeutic agents or composition:Acacia, Acesulfame Potassium, Acetic Acid—Glacial, Acetone,Acetyltributyl Citrate, Acetyltriethyl Citrate, Adipic Acid, Agar,Albumin, Alcohol, Alginic Acid, Aliphatic Polyesters, Alitame, AlmondOil, Alpha Tocopherol, Aluminum Hydroxide Adjuvant, AluminumMonostearate, Aluminum Oxide, Aluminum Phosphate Adjuvant, AmmoniaSolution, Ammonium Alginate, Ammonium Chloride, Ascorbic Acid, AscorbylPalmitate, Aspartame, Attapulgite, Bentonite, Benzalkonium Chloride,Benzethonium Chloride, Benzoic Acid, Benzyl Alcohol, Benzyl Benzoate,Boric Acid, Bronopol, Butylated Hydroxyanisole, ButylatedHydroxytoluene, Butylene Glycol, Butylparaben, Calcium Acetate, CalciumAlginate, Calcium Carbonate, Calcium Chloride, Calcium Hydroxide,Calcium Lactate, Calcium Phosphate—Dibasic Anhydrous, CalciumPhosphate—Dibasic Dihydrate, Calcium Phosphate—Tribasic, CalciumSilicate, Calcium Stearate, Calcium Sulfate, Canola Oil, Carbomer,Carbon Dioxide, Carboxymethylcellulose Calcium, CarboxymethylcelluloseSodium, Carrageenan, Castor Oil, Castor Oil—Hydrogenated,Cellulose—Microcrystalline, Cellulose—Microcrystalline andCarboxymethylcellulose Sodium, Cellulose—Powdered, Cellulose—SilicifiedMicrocrystalline, Cellulose Acetate, Cellulose Acetate Phthalate,Ceratonia, Ceresin, Cetostearyl Alcohol, Cetrimide, Cetyl Alcohol,Cetylpyridinium Chloride, Chitosan, Chlorhexidine, Chlorobutanol,Chlorocresol, Chlorodifluoroethane (HCFC), Chlorofluorocarbons (CFC),Chloroxylenol, Cholesterol, Citric Acid Monohydrate, Coconut Oil,Colloidal Silicon Dioxide, Coloring Agents, Copovidone, Corn Oil, CornStarchand Pregelatinized Starch, Cottonseed Oil, Cresol, CroscarmelloseSodium, Crospovidone, Cyclodextrins, Cyclomethicone, DenatoniumBenzoate, Dextrates, Dextrin, Dextrose, Dibutyl Phthalate, DibutylSebacate, Diethanolamine, Diethyl Phthalate, Difluoroethane (HFC),Dimethicone, Dimethyl Ether, Dimethyl Phthalate, Dimethyl Sulfoxide,Dimethylacetamide, Disodium Edetate, Docusate Sodium, Edetic Acid,Erythorbic Acid, Erythritol, Ethyl Acetate, Ethyl Lactate, Ethyl Maltol,Ethyl Oleate, Ethyl Vanillin, Ethylcellulose, Ethylene Glycol Stearates,Ethylene Vinyl Acetate, Ethylparaben, Fructose, Fumaric Acid, Gelatin,Glucose—Liquid, Glycerin, Glyceryl Behenate, Glyceryl Monooleate,Glyceryl Monostearate, Glyceryl Palmitostearate, Glycine, Glycofurol,Guar Gum, Hectorite, Heptafluoropropane (HFC), Hexetidine, Hydrocarbons(HC), Hydrochloric Acid, Hydrophobic Colloidal Silica, HydroxyethylCellulose, Hydroxyethylmethyl Cellulose, Hydroxypropyl Betadex,Hydroxypropyl Cellulose, Hydroxypropyl Cellulose—Low-substituted,Hydroxypropyl Starch, Hypromellose, Hypromellose Acetate Succinate,Hypromellose Phthalate, Imidurea, Inulin, Iron Oxides, Isomalt,Isopropyl Alcohol, Isopropyl Myristate, Isopropyl Palmitate, Kaolin,Lactic Acid, Lactitol, Lactose—Anhydrous, Lactose—Inhalation,Lactose—Monohydrate, Lactose—Monohydrate and Corn Starch,Lactose—Monohydrate and Microcrystalline Cellulose, Lactose—Monohydrateand Povidone, Lactose—Monohydrate and Powdered Cellulose,Lactose—Spray-Dried, Lanolin, Lanolin—Hydrous, Lanolin Alcohols, LaurieAcid, Lecithin, Leucine, Linoleic Acid, Macrogol 15 Hydroxystearate,Magnesium Aluminum Silicate, Magnesium Carbonate, Magnesium Oxide,Magnesium Silicate, Magnesium Stearate, Magnesium Trisilicate, MaleicAcid, Malic Acid, Maltitol, Maltitol Solution, Maltodextrin, Maltol,Maltose, Mannitol, Medium-chain Triglycerides, Meglumine, Menthol,Methionine, Methylcellulose, Methylparaben, Mineral Oil, MineralOil—Light, Mineral Oil and Lanolin Alcohols, Monoethanolamine,Monosodium Glutamate, Monothioglycerol, Myristic Acid, Myristyl Alcohol,Neohesperidin Dihydrochalcone, Neotame, Nitrogen, Nitrous Oxide,Octyldodecanol, Oleic Acid, Oleyl Alcohol, Olive Oil, Palmitic Acid,Paraffin, Peanut Oil, Pectin, Pentetic Acid, Petrolatum, Petrolatum andLanolin Alcohols, Phenol, Phenoxyethanol, Phenylethyl Alcohol,Phenylmercuric Acetate, Phenylmercuric Borate, Phenylmercuric Nitrate,Phospholipids, Phosphoric Acid, Polacrilin Potassium, Poloxamer,Polycarbophil, Polydextrose, Poly (DL-Lactic Acid), Polyethylene Glycol,Polyethylene Oxide, Polymethacrylates, Poly(methyl vinylether/maleicanhydride), Polyoxyethylene Alkyl Ethers, Polyoxyethylene Castor OilDerivatives, Polyoxyethylene Sorbitan Fatty Acid Esters, PolyoxyethyleneStearates, Polyoxylglycerides, Polyvinyl Acetate Phthalate, PolyvinylAlcohol, Potassium Alginate, Potassium Alum, Potassium Benzoate,Potassium Bicarbonate, Potassium Chloride, Potassium Citrate, PotassiumHydroxide, Potassium Metabisulfite, Potassium Sorbate, Povidone,Propionic Acid, Propyl Gallate, Propylene Carbonate, Propylene Glycol,Propylene Glycol Alginate, Propylparaben, Propylparaben Sodium,Pyrrolidone, Raffinose, Saccharin, Saccharin Sodium, Safflower Oil,Saponite, Sesame Oil, Shellac, Simethicone, Sodium Acetate, SodiumAlginate, Sodium Ascorbate, Sodium Benzoate, Sodium Bicarbonate, SodiumBorate, Sodium Carbonate, Sodium Chloride, Sodium Citrate Dihydrate,Sodium Cyclamate, Sodium Formaldehyde Sulfoxylate, Sodium Hyaluronate,Sodium Hydroxide, Sodium Lactate, Sodium Lauryl Sulfate, SodiumMetabisulfite, Sodium Phosphate—Dibasic, Sodium Phosphate—Monobasic,Sodium Propionate, Sodium Starch Glycolate, Sodium Stearyl Fumarate,Sodium Sulfite, Sodium Thiosulfate, Sorbic Acid, Sorbitan Esters(Sorbitan Fatty Acid Esters), Sorbitol, Soybean Oil, Starch,Starch—Pregelatinized, Starch—Sterilizable Maize, Stearic Acid, StearylAlcohol, Sucralose, Sucrose, Sucrose Octaacetate, Sugar—Compressible,Sugar—Confectioner's, Sugar Spheres, Sulfobutylether b-Cyclodextrin,Sulfur Dioxide, Sulfuric Acid, Sunflower Oil, Suppository Bases—HardFat, Tagatose, Talc, Tartaric Acid, Tetrafluoroethane (HFC), Thaumatin,Thimerosal, Thymol, Titanium Dioxide, Tragacanth, Trehalose, Triacetin,Tributyl Citrate, Tricaprylin, Triethanolamine, Triethyl Citrate,Triolein, Vanillin, Vegetable Oil—Hydrogenated, Vitamin E PolyethyleneGlycol Succinate, Water, Wax—Anionic Emulsifying, Wax—Carnauba,Wax—Cetyl Esters, Wax—Microcrystalline, Wax—Nonionic Emulsifying,Wax—White, Wax—Yellow, Xanthan Gum, Xylitol, Zein, Zinc Acetate, and/orZinc Stearate.

The dosage unit or composition comprising the dosage unit can furthercomprise one or more excipients. The dosage unit or composition canfurther comprise one or more excipients, wherein the one or moreexcipients can be selected from a group consisting of: detackifiers,anti-foaming agents, buffering agents, polymers, antioxidants,preservatives, chelating agents, viscomodulators, tonicifiers,flavorants, colorants, odorants, opacifiers, suspending agents, binders,fillers, plasticizers, lubricants, and mixtures thereof.

The dosage unit or composition can further comprise one or morecytochrome p450 inhibitors. The dosage unit or composition can furthercomprise one or more cytochrome p450 inhibitors wherein the one or morecytochrome p450 inhibitors can fully or partially inhibit a cytochromep450 selected from a group consisting of: CYP1, CYP1A1, CYP1A2, CYP1B1,CYP2, CYP2A6, CYP2A7, CYP2A13, CYP2B6, CYP2C8, CYP2C9, CYP2C18, CYP2C19,CYP2D6, CYP2E1, CYP2F1, CYP2J2, CYP2R1, CYP2S1, CYP2U1, CYP2W1, CYP3,CYP3A4, CYP3A5, CYP3A7, CYP3A43, CYP4, CYP4A11, CYP4A22, CYP4B1, CYP4F2,CYP4F3, CYP4F8, CYP4F11, CYP4F12, CYP4F22, CYP4V2, CYP4X1, CYP4Z1, CYP5,CYP5A1, CYP7, CYP7A1, CYP7B1, CYP8, CYP8A1, CYP8B1, CYP11, CYP11A1,CYP11B1, CYP11B2, CYP17, CYP17A1, CYP19, CYP19A1, CYP20, CYP20A1, CYP21,CYP21A2, CYP24, CYP24A1, CYP26, CYP26A1, CYP26B1, CYP26C1, CYP27,CYP27A1, CYP27B1, CYP27C1, CYP39, CYP39A1, CYP46, CYP46A1, CYP51, andCYP51A1. The dosage unit or composition can also comprise one or morecytochrome p450 inhibitors wherein the one or more cytochrome p450inhibitors can fully or partially inhibit CYP1. The dosage unit orcomposition can also comprise one or more cytochrome p450 inhibitorswherein the one or more cytochrome p450 inhibitors can fully orpartially inhibit CYP1A2. The dosage unit or composition can alsocomprise one or more CYP1A2 inhibitors wherein the one or more CYP1A2inhibitors can be selected from a group consisting of: fluoroquinolone,selective serotonin reuptake inhibitor (SSRI), calcium channel blocker,herbal tea, naringenin, H2-receptor antagonist, antiarrhythmic agent,interferon, xanthotoxin, mibefradil, cumin, turmeric, and isoniazid. Thedosage unit or composition can also further comprise one or more CYP1A2inhibitors wherein the one or more CYP1A2 inhibitors can be grapefruitjuice. The dosage unit or composition can also further comprise one ormore CYP1A2 inhibitors wherein the one or more CYP1A2 inhibitors can benaringenin.

The dosage unit or composition can further comprise one or moreβ-adrenergic agonists. The dosage unit or composition can also furthercomprise one or more β-adrenergic agonists wherein the one or moreβ-adrenergic agonists can be a β₁-adrenergic agonist and/or32-adrenergic agonist. The dosage unit or composition can also furthercomprise one or more β-adrenergic agonists wherein the one or moreβ-adrenergic agonists can be a β₁-adrenergic agonist. The dosage unit orcomposition can also further comprise one or more β-adrenergic agonistswherein the one or more β-adrenergic agonists can be a β₁-adrenergicagonist selected from a group consisting of: dobutamine, isoproterenol,xamoterol and epinephrine. The dosage unit or composition can alsofurther comprise one or more β-adrenergic agonists wherein the one ormore β-adrenergic agonists can be a β₂-adrenergic agonist. The dosageunit or composition can also further comprise one or more β-adrenergicagonists wherein the one or more β-adrenergic agonists can be aβ₂-adrenergic agonist selected from a group consisting of: albuterol,levalbuterol, fenoterol, formoterol, isoproterenol (β₁ and (β₂),metaproterenol, salmeterol, terbutaline, clenbuterol, isoetarine,pirbuterol, procaterol, ritodrine, and epinephrine. The dosage unit orcomposition can also further comprise one or more β-adrenergic agonistswherein the one or more β-adrenergic agonists can be selected from agroup consisting of: arbutamine, befunolol,bromoacetylalprenololmenthane, broxaterol, cimaterol, cirazoline,denopamine, dopexamine, etilefrine, hexoprenaline, higenamine,isoxsuprine, mabuterol, methoxyphenamine, nylidrin, oxyfedrine,prenalterol, ractopamine, reproterol, rimiterol, tretoquinol,tulobuterol, zilpaterol, and zinterol.

Diagnosing and Treating Loss and/or Distortion of Taste or Smell

Also disclosed are methods of diagnosing loss and/or distortion of tasteor smell in a subject, the methods comprising (a) obtaining one or morebiological samples from the subject; (b) measuring a level of one ormore members of the hedgehog signaling pathway in the one or morebiological samples from the subject; (c) diagnosing the subject withloss and/or distortion of taste or smell based upon the level of one ormore members of the hedgehog signaling pathway that is lower than athreshold level; and (d) administering to the subject a treatment fortaste or smell disorder. Any of the methods of diagnosing loss and/ordistortion of taste or smell disclosed herein can be used in combinationwith any of the pharmaceutical dosage units or composition disclosedherein.

Making Drug Compositions

In an additional aspect of the invention, disclosed herein are methodsof making a pharmaceutical dosage unit comprising combining one or morecGMP activators and one or more cAMP activators, in any combinationthereof.

The methods can comprise one or more cGMP activators wherein the one ormore cGMP activators can be selected from a group consisting of:3-(5′-hydroxymethyl-2′-furyl)-1-benzylindazole (YC-1), YC-1 derivatives,anthranilic acids derivatives, ataciguat (HMR1766), benzydamine analogs,CFM1517, A-350619, nitrovasodilators, molsidomine, nitroxyl (HNO), BAY41-2272, BAY 41-8543, BAY 58-2667, cinaciguat (BAY 58-2667), andriociguat (BAY 63-2521). The methods can also comprise one or more cGMPactivators wherein the one or more cGMP activators can compriseriociguat. The methods can comprise one or more cAMP activators whereinthe one or more cAMP activators can be selected from a group consistingof: 3-(5′-hydroxymethyl-2′-furyl)-1-benzylindazole (YC-1), glucagon, PDEinhibitors, prostaglandin E1 (PGE1; pharmaceutically known asalprostadil), forskolin, and β-adrenergic agonists.

The methods can comprise one or more cAMP activators wherein the one ormore cAMP activators can further comprise one or more PDE inhibitorsand/or forskolin.

The methods can comprise one or more cAMP activators wherein the one ormore cAMP activators can be forskolin.

The one or more PDE inhibitors can be a non-selective PDE inhibitor, aPDE-1 selective inhibitor, a PDE-2 selective inhibitor, a PDE-3selective inhibitor, a PDE-4 selective inhibitor, a PDE-5 selectiveinhibitor, a PDE-10 selective inhibitor, or any combination thereof. Themethods can also comprise one or more PDE inhibitors wherein the one ormore one or more PDE inhibitors can be a selective PDE inhibitor. Themethods can also comprise one or more PDE inhibitors wherein the one ormore PDE inhibitors can be a non-selective PDE inhibitor that can be amethylxanthine derivative. The methods can also comprise methylxanthinederivative that can be caffeine, theophylline, doxophylline,cipamphylline, neuphylline, pentoxiphylline, or diprophylline. Themethods can also comprise the methylxanthine derivative that can betheophylline. The methods can also comprise a PDE 1 inhibitor can bevinpocetine, compound KS505a, bepril, flunarizine, amiodarone,zaprinast, 8-methoxymethyl IPMX, SCH 51866, Nimodipine, or IC224. Themethods can also comprise a PDE 2 inhibitor that can be EHNA. Themethods can also comprise a PDE 3 inhibitor that can be enoximone,milrinone (Primacor), amrinone, cilostamide, cilostazol (Pletal),trequinsin, inamrinone, anagrelide, pimobendan, lixazinone, ordihydro-pyridazinone. The methods can also comprise a PDE 4 inhibitorthat can be mesembrine, rolipram, ibudilast, roflumilast (Daxas),cilomilast (Airflo), piclamilast, luteolin, drotaverine, ordenbufylline. The methods can also comprise a PDE 5 inhibitor that canbe sildenafil, tadalafil, vardenafil, udenafil and avanafil,dipyridamole, icariin, 4-Methylpiperazine, Pyrazolo Pyrimidin-7-1,cilomilast, or zaprinast. The methods can also comprise a PDE6-selectiveinhibitors that can be zaprinast, dipyridamole, vardenafil, ortadalafil. The methods can also comprise a PDE7-selective inhibitorsthat can be quinazoline type PDE7 inhibitor, dipyridamole, orthiadiazole. The methods can also comprise a PDE8-selective inhibitorsthat can be dipyridamole. The methods can also comprise a PDE9-selectiveinhibitors can be zaprinast. The methods can also comprise a PDE 10inhibitor that can be papaverine, OMS824 (from Omeros Corporation),and/or PF-2545920 (from Pfizer). The methods can also comprise aPDE11-selective inhibitors that can be tadalafil, zaprinast, ordipyridamole.

The dosage unit can be formed by combining a non-selective PDEinhibitor, forskolin, and riociguat. The dosage unit can be formed bycombining a selective PDE inhibitor, forskolin, and riociguat. Thedosage unit can be formed by combining a non-selective PDE inhibitor,theophylline, and riociguat. The dosage unit can be formed by combininga selective PDE inhibitor, theophylline, and riociguat. The dosage unitcan be formed by combining a non-selective PDE inhibitor and riociguat.The dosage unit can be formed by combining a selective PDE inhibitor andriociguat. The dosage unit can be formed by combining theophylline andriociguat. The dosage unit can be formed by combining forskolin andriociguat. The dosage unit can be formed by combining theophylline,forskolin, and riociguat.

Riociguat can be combined or present in an amount selected from a groupconsisting of: greater than 0.0 μg to 1 μg, 0.5 μg to 2 μg, 1.5 μg to3.0 μg, 2.5 μg to 10 μg, 5 μg to 15 μg, 12.5 μg to 30 μg, 25 μg to 50μg, 40 μg to 80 μg, 60 μg to 100 μg, 90 μg to 120 μg, 110 μg to 130 μg,125 μg to 150 μg, 140 μg to 180 μg, 170 μg to 200 μg, 200 μg to 230 μg,215 μg to 240 μg, 235 μg to less than 250 μg, less than 250 μg andgreater than about 0.0 μg to about 1 μg, about 0.5 μg to about 2 μg,about 1.5 μg to about 3.0 μg, about 2.5 μg to about 10 μg, about 5 μg toabout 15 μg, about 12.5 μg to about 30 μg, about 25 μg to about 50 μg,about 40 μg to about 80 μg, about 60 μg to about 100 μg, about 90 μg toabout 120 μg, about 110 μg to about 130 μg, about 125 μg to about 150μg, about 140 μg to about 180 μg, about 170 μg to about 200 μg, about200 μg to about 230 μg, about 215 μg to about 240 μg, about 235 μg toless than about 250 μg.

Theophylline can be combined or present in an amount selected from agroup consisting of: less than 45 mg, 30 mg, 15 mg, 10 mg, 5 mg, 1 mg,500 μg, 250 μg, 120 μg, 80 μg, 40 μg, or 20 μg and less than about 45mg, about 30 mg, about 15 mg, about 10 mg, about 5 mg, about 1 mg, about500 μg, about 250 μg, about 120 μg, about 80 μg, about 40 μg, or about20 μg.

Forskolin can be combined or present in an amount selected from a groupconsisting of: less than 500 mg to 450 mg, 475 mg to 425 mg, 435 mg to400 mg, 415 mg to 300 mg, 325 mg to 250 mg, 275 mg to 150 mg, 200 mg to100 mg, 135 mg to 80 mg, 95 mg to 65 mg, 75 mg to 50 mg, 60 mg to 40 mg,45 mg to 25 mg, 30 mg to 20 mg, 15 mg to 5 mg, 10 mg to 2.5 mg, 3.5 mgto 1 mg, 2 mg to greater than 0 mg and less than about 500 mg to about450 mg, about 475 mg to about 425 mg, about 435 mg to about 400 mg,about 415 mg to about 300 mg, about 325 mg to about 250 mg, about 275 mgto about 150 mg, about 200 mg to about 100 mg, about 135 mg to about 80mg, about 95 mg to about 65 mg, about 75 mg to about 50 mg, about 60 mgto about 40 mg, about 45 mg to about 25 mg, about 30 mg to about 20 mg,about 15 mg to about 5 mg, about 10 mg to about 2.5 mg, about 3.5 mg toabout 1 mg, about 2 mg to greater than about 0 mg.

In some aspects of the invention, riociguat, theophylline, and forskolincan be combined. For example, (a) riociguat can be combined or presentin an amount selected from a group consisting of: greater than 0.0 μg to1 μg, 0.5 μg to 2 μg, 1.5 μg to 3.0 μg, 2.5 μg to 10 μg, 5 μg to 15 μg,12.5 μg to 30 μg, 25 μg to 50 μg, 40 μg to 80 μg, 60 μg to 100 μg, 90 μgto 120 μg, 110 μg to 130 μg, 125 μg to 150 μg, 140 μg to 180 μg, 170 μgto 200 μg, 200 μg to 230 μg, 215 μg to 240 μg, 235 μg to less than 250μg, and less than 250 μg, and greater than about 0.0 μg to about 1 μg,about 0.5 μg to about 2 μg, about 1.5 μg to about 3.0 μg, about 2.5 μgto about 10 μg, about 5 μg to about 15 μg, about 12.5 μg to about 30 μg,about 25 μg to about 50 μg, about 40 μg to about 80 μg, about 60 μg toabout 100 μg, about 90 μg to about 120 μg, about 110 μg to about 130 μg,about 125 μg to about 150 μg, about 140 μg to about 180 μg, about 170 μgto about 200 μg, about 200 μg to about 230 μg, about 215 μg to about 240μg, and about 235 μg to less than 250 μg; (b) theophylline can becombined or present in an amount selected from a group consisting of:less than 45 mg, 30 mg, 15 mg, 10 mg, 5 mg, 1 mg, 500 μg, 250 μg, 120μg, 80 μg, 40 μg, or 20 μg and less than about 45 mg, about 30 mg, about15 mg, about 10 mg, about 5 mg, about 1 mg, about 500 μg, about 250 μg,about 120 μg, about 80 μg, about 40 μg, or about 20 μg; and (c)forskolin can be combined or present in an amount selected from a groupconsisting of: less than 500 mg to 450 mg, 475 mg to 425 mg, 435 mg to400 mg, 415 mg to 300 mg, 325 mg to 250 mg, 275 mg to 150 mg, 200 mg to100 mg, 135 mg to 80 mg, 95 mg to 65 mg, 75 mg to 50 mg, 60 mg to 40 mg,45 mg to 25 mg, 30 mg to 20 mg, 15 mg to 5 mg, 10 mg to 2.5 mg, 3.5 mgto 1 mg, and 2 mg to greater than 0 mg, and less than about 500 mg toabout 450 mg, about 475 mg to about 425 mg, about 435 mg to about 400mg, about 415 mg to about 300 mg, about 325 mg to about 250 mg, about275 mg to about 150 mg, about 200 mg to about 100 mg, about 135 mg toabout 80 mg, about 95 mg to about 65 mg, about 75 mg to about 50 mg,about 60 mg to about 40 mg, about 45 mg to about 25 mg, about 30 mg toabout 20 mg, about 15 mg to about 5 mg, about 10 mg to about 2.5 mg,about 3.5 mg to about 1 mg, and about 2 mg to greater than 0 mg.

The dosage unit or composition comprising the dosage unit can be formedinto a dosage unit suitable for administration by a method selected froma group consisting of: oral administration, transmucosal administration,buccal administration, inhalation administration, intranasaladministration, parental administration, intravenous administration,subcutaneous administration, intramuscular administration, sublingualadministration, transdermal administration, and rectal administration.For ease of use, the dosage unit or composition comprising the dosageunit can be formed into a dosage unit suitable for oral administration,inhalational administration, nasal administration, or any combinationthereof. The dosage unit or composition comprising the dosage unit canbe a liquid.

The dosage unit or composition comprising the dosage unit can have a pHof greater than 7.0. For example, the dosage unit or compositioncomprising the dosage unit can have a pH of greater than 7.1. The dosageunit or composition comprising the dosage unit can have a pH of greaterthan 7.5. The dosage unit or composition comprising the dosage unit canhave a pH of greater than 8.0. The dosage unit or composition comprisingthe dosage unit can have a pH of greater than 9.0.

The dosage unit or composition comprising the dosage unit can furthercomprise one or more excipients. The dosage unit can be formed tocomprise one or more excipients, wherein the one or more excipients canbe selected from a group consisting of: detackifiers, anti-foamingagents, buffering agents, polymers, antioxidants, preservatives,chelating agents, viscomodulators, tonicifiers, flavorants, colorants,odorants, opacifiers, suspending agents, binders, fillers, plasticizers,lubricants, and mixtures thereof.

The dosage unit or composition comprising the dosage unit can furthercomprise combining one or more cytochrome p450 inhibitors. The dosageunit or composition comprising the dosage unit can also comprise one ormore cytochrome p450 inhibitors wherein the cytochrome p450 inhibitorscan fully or partially inhibit a cytochrome selected from a groupconsisting of: CYP1, CYP1A1, CYP1A2, CYP1B1, CYP2, CYP2A6, CYP2A7,CYP2A13, CYP2B6, CYP2C8, CYP2C9, CYP2C18, CYP2C19, CYP2D6, CYP2E1,CYP2F1, CYP2J2, CYP2R1, CYP2S1, CYP2U1, CYP2W1, CYP3, CYP3A4, CYP3A5,CYP3A7, CYP3A43, CYP4, CYP4A11, CYP4A22, CYP4B1, CYP4F2, CYP4F3, CYP4F8,CYP4F11, CYP4F12, CYP4F22, CYP4V2, CYP4X1, CYP4Z1, CYP5, CYP5A1, CYP7,CYP7A1, CYP7B1, CYP8, CYP8A1, CYP8B1, CYP11, CYP11A1, CYP11B1, CYP11B2,CYP17, CYP17A1, CYP19, CYP19A1, CYP20, CYP20A1, CYP21, CYP21A2, CYP24,CYP24A1, CYP26, CYP26A1, CYP26B1, CYP26C1, CYP27, CYP27A1, CYP27B1,CYP27C1, CYP39, CYP39A1, CYP46, CYP46A1, CYP51, and CYP51A1. The dosageunit or composition comprising the dosage unit can also comprise one ormore cytochrome p450 inhibitors wherein the cytochrome p450 inhibitorscan fully or partially inhibit CYP1. The dosage unit or compositioncomprising the dosage unit can also comprise one or more cytochrome p450inhibitors wherein the cytochrome p450 inhibitors can fully or partiallyinhibit CYP1A2. The dosage unit or composition comprising the dosageunit can also comprise one or more CYP1A2 inhibitors wherein the CYP1A2inhibitors can be selected from a group consisting of: fluoroquinolone,selective serotonin reuptake inhibitor (SSRI), calcium channel blocker,herbal tea, naringenin, H2-receptor antagonist, antiarrhythmic agent,interferon, xanthotoxin, mibefradil, cumin, turmeric, and isoniazid. Thedosage unit or composition comprising the dosage unit can also compriseone or more CYP1A2 inhibitors wherein the CYP1A2 inhibitors can begrapefruit juice. The dosage unit or composition comprising the dosageunit can also comprise one or more CYP1A2 inhibitors wherein the CYP1A2inhibitors can be naringenin.

The dosage unit or composition comprising the dosage unit can furthercomprise combining one or more β-adrenergic agonists. The dosage unit orcomposition comprising the dosage unit can also comprise combining oneor more β-adrenergic agonists wherein the one or more β-agonists can bea β₁-adrenergic agonist and/or β2-adrenergic agonist. The dosage unit orcomposition comprising the dosage unit can also comprise one or moreβ-adrenergic agonists wherein the one or more β-agonists can be aβ₁-adrenergic agonist. The dosage unit or composition comprising thedosage unit can also comprise one or more β-adrenergic agonists whereinthe one or more β-agonists can be a β₁-adrenergic agonist selected froma group consisting of dobutamine, isoproterenol, xamoterol andepinephrine. The dosage unit or composition comprising the dosage unitcan also comprise one or more β-adrenergic agonists wherein the one ormore β-agonists can be a β₂-adrenergic agonist. The dosage unit orcomposition comprising the dosage unit can also comprise one or moreβ-adrenergic agonists wherein the one or more β-agonists can be aβ₂-adrenergic agonist selected from a group consisting of: albuterol,levalbuterol, fenoterol, formoterol, isoproterenol (β₁ and β₂),metaproterenol, salmeterol, terbutaline, clenbuterol, isoetarine,pirbuterol, procaterol, ritodrine, and epinephrine. The dosage unit orcomposition comprising the dosage unit can also comprise one or moreβ-adrenergic agonists wherein the one or more β-agonists can be selectedfrom a group consisting of: arbutamine, befunolol,bromoacetylalprenololmenthane, broxaterol, cimaterol, cirazoline,denopamine, dopexamine, etilefrine, hexoprenaline, higenamine,isoxsuprine, mabuterol, methoxyphenamine, nylidrin, oxyfedrine,prenalterol, ractopamine, reproterol, rimiterol, tretoquinol,tulobuterol, zilpaterol, and zinterol.

Kits for Diagnosis and/or Treatment

A kit that can be used to diagnose loss and/or distortion of taste orsmell, e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia,dysgeusia, phantogeusia, and/or ageusia is contemplated as part of theinvention.

In an additional aspect of the invention, disclosed herein is a kit thatcan comprise: (a) antibodies that bind one or more members of thehedgehog signaling pathway; and (b) an insert that describes how todiagnose a subject with loss and/or distortion of taste or smell, e.g.,hyposmia, dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia,phantogeusia, and/or ageusia based upon the level of one or more membersof the hedgehog signaling pathway that can be lower than a thresholdlevel.

The antibodies can be SHH specific antibodies. The antibodies can be IHHspecific antibodies. The antibodies can be DHH specific antibodies.

The kit can further comprise an ELISA assay.

The kit can further comprise one or more therapeutic agents capable ofmaintaining and/or increasing one or more members of the hedgehogsignaling pathway.

Drug Compositions Comprising Riociguat

Riociguat is believed to be helpful in treating two forms of pulmonaryhypertension (PH): chronic thromboembolic pulmonary hypertension (CTEPH)and pulmonary arterial hypertension (PAH). However, the dosages can betypically in the milligram range and can be given as an oral dosage.However, if the dosage form is changed, for example, into a formsuitable for nasal administration, riociguat can be given at a muchlower dosage (in the microgram or lower range). Additionally, whenriociguat is presented in other dosage forms, it can be effective intreating other diseases, such as pulmonary hypertension, loss and/ordistortion of taste or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia.

In an additional aspect of the invention, disclosed herein is apharmaceutical dosage unit comprising riociguat. A pharmaceutical dosageunit with riociguat in the microgram or lower range, e.g., below 250micrograms, is also disclosed.

The ricociguat can be suitable for administration by a method selectedfrom a group consisting of: transmucosal administration, inhalationadministration, intranasal administration, parental administration,intravenous administration, subcutaneous administration, intramuscularadministration, sublingual administration, transdermal administration,and rectal administration. For ease of use, the ricociguat can besuitable for administration by inhalation administration, intranasaladministration, intravenous administration, or any combination thereof.

Riociguat can be present in an amount selected from a group consistingof: greater than 0.0 μg to 1 μg, 0.5 μg to 2 μg, 1.5 μg to 3.0 μg, 2.5μg to 10 μg, 5 μg to 15 μg, 12.5 μg to 30 μg, 25 μg to 50 μg, 40 μg to80 μg, 60 μg to 100 μg, 90 μg to 120 μg, 110 μg to 130 μg, 125 μg to 150μg, 140 μg to 180 μg, 170 μg to 200 μg, 200 μg to 230 μg, 215 μg to 240μg, 235 μg to less than 250 μg, less than 250 μg and greater than about0.0 μg to about 1 μg, about 0.5 μg to about 2 μg, about 1.5 μg to about3.0 μg, about 2.5 μg to about 10 μg, about 5 μg to about 15 μg, about12.5 μg to about 30 μg, about 25 μg to about 50 μg, about 40 μg to about80 μg, about 60 μg to about 100 μg, about 90 μg to about 120 μg, about110 μg to about 130 μg, about 125 μg to about 150 μg, about 140 μg toabout 180 μg, about 170 μg to about 200 μg, about 200 μg to about 230μg, about 215 μg to about 240 μg, about 235 μg to less than about 250μg. Riociguat can be present in an amount less than 250 μg to greaterthan 0 or about less than 250 μg to greater than 0. Riociguat can bepresent in an amount less than 200 μg to greater than 0 or about lessthan 200 μg to greater than 0. Riociguat can be present in an amountless than 150 μg to greater than 0 or about less than 150 μg to greaterthan 0. Riociguat can be present in an amount less than 100 μg togreater than 0 or about less than 100 μg to greater than 0. Riociguatcan be present in an amount less than 50 μg to greater than 0 or aboutless than 50 μg to greater than 0.

It is contemplated that the dosage unit can be steroid-free.

Methods of Treatment Comprising Riociguat

Although ricociguat can be effective in treating pulmonary hypertensionwith milligram oral dosages. The inventors have found that whenricociguat is reformulated, some conditions, including but not limitedto pulmonary hypertension, bone-related disorders, loss and/ordistortion of taste or smell, e.g., hyposmia, dysosmia, anosmia,phantosmia, hypogeusia, dysgeusia, phantogeusia, and/or ageusia, can betreated with microgram dosages.

In an additional aspect of the invention, disclosed herein are methodsfor treating disease comprising treating a subject in need thereof, withriociguat.

For example, the subject can be treated for pulmonary hypertension. Thesubject can also be treated for chronic thromboembolic pulmonaryhypertension. The subject can also be treated for pulmonary arterialhypertension. The subject can also be treated for bone relateddisorders.

The ricociguat can be given by transmucosal administration, inhalationadministration, intranasal administration, parental administration,intravenous administration, subcutaneous administration, intramuscularadministration, sublingual administration, transdermal administration,and rectal administration. For ease, the ricociguat can be given byinhalation administration, intranasal administration, intravenousadministration, or any combination thereof.

The riociguat can be given and/or present in an amount selected from agroup consisting of: greater than 0.0 μg to 1 μg, 0.5 μg to 2 μg, 1.5 μgto 3.0 μg, 2.5 μg to 10 μg, 5 μg to 15 μg, 12.5 μg to 30 μg, 25 μg to 50μg, 40 μg to 80 μg, 60 μg to 100 μg, 90 μg to 120 μg, 110 μg to 130 μg,125 μg to 150 μg, 140 μg to 180 μg, 170 μg to 200 μg, 200 μg to 230 μg,215 μg to 240 μg, 235 μg to less than 250 μg, less than 250 μg andgreater than about 0.0 μg to about 1 μg, about 0.5 μg to about 2 μg,about 1.5 μg to about 3.0 μg, about 2.5 μg to about 10 μg, about 5 μg toabout 15 μg, about 12.5 μg to about 30 μg, about 25 μg to about 50 μg,about 40 μg to about 80 μg, about 60 μg to about 100 μg, about 90 μg toabout 120 μg, about 110 μg to about 130 μg, about 125 μg to about 150μg, about 140 μg to about 180 μg, about 170 μg to about 200 μg, about200 μg to about 230 μg, about 215 μg to about 240 μg, about 235 μg toless than about 250 μg. The riociguat can be given and/or present in anamount less than 250 μg to greater than 0 or about less than 250 μg togreater than 0. The riociguat can be given and/or present in an amountless than 200 μg to greater than 0 or about less than 200 μg to greaterthan 0. The riociguat can be given and/or present in an amount less than150 μg to greater than 0 or about less than 150 μg to greater than 0.The riociguat can be given and/or present in an amount less than 100 μgto greater than 0 or about less than 100 μg to greater than 0. Theriociguat can be given and/or present in an amount less than 50 μg togreater than 0 or about less than 50 μg to greater than 0.

Treating Appetite Loss

Cancer patients undergoing chemotherapy can often lose significantamounts of body weight. This loss of weight can be at least partiallyattributed to decrease in appetite (also known as anorexia).

It is also contemplated by the methods described herein that appetiteloss can be treated with one or more therapeutic agents. This decreasein appetite loss may or may not be associated with a disease or atreatment of disease. For example, anorexia is generally can be treatedby the methods disclosed herein. The appetite loss can result fromcancer, with or without chemotherapy treatment. Other diseases that canresult in appetite loss and can be treated by the methods disclosedherein include but are not limited to Addison's disease, amyloidosis,asthma, cancer, cat scratch disease, acute lymphoblastic leukemia,coxsackie virus, dementia, depression, encopresis, gastroespophagealreflux disease, acid reflux, infectious mononucleosis, kidney failure,legionnaires' disease, leigh's disease, peptic ulcer, postpartumdepression, psychotic disorders, rheumatoid arthritis, rocky mountainspotted fever, stress, anthrax, anorexia nervosa, pernicious anemia,alcohol withdrawal, migraine headaches, vitamin B12 deficiency, acutemountain sickness, stroke, thyroid diseases, yellow fever, liverdisease, chronic obstructive pulmonary disease, heart failure,hepatitis, HIV, pregnancy, bowel disease, disease of thegastrointestinal tract (e.g., gallbladder disease, crohn's disease,irritable bowel syndrome, appendicitis), brain damage (e.g., fromtrauma), hormone (endocrine) disease, inflammation (e.g., from chronicinfectious or chronic inflammatory diseases, or loss of taste. Theappetite loss that results from each of these diseases can be treatedindividually. Furthermore, medication or drugs (e.g., including but notlimited to digoxin, cocaine, codeine, demerol, morphine, antibiotics,amphetamines, methamphetamine, chemotherapy agents, common coldmedicines, and cough & stuffy nose decongestants) related appetite losscan also be treated by the methods disclosed herein. Other appetite lossassociated with infections such as flu, mumps, syphilis, vasculitis,giardiasis, listeriosis, AIDS/HIV, pneumonia, chickenpox, strep throat,yellow fever, typhoid fever, leishmaniasis, gastroenteritis,mononucleosis, schistosomiasis, cat scratch fever, coxsackie disease,hookworm disease, Rocky Mountain spotted fever, and food poisoning—E.coli enteritis, can be treated by the methods described herein.

Disclosed herein is a method of treating appetite loss that can compriseadministering to a subject in need thereof a dose of one or moretherapeutic agents, e.g., a PDE inhibitor. The subject can be a subjectin need thereof. For example, a subject with appetite loss and/or withany of the diseases (or taking any of the medications or drugs) listedabove can be a subject in need thereof. For example, the subject in needthereof can be a cancer patient. The cancer patient may or may not beundergoing chemotherapy.

One or more therapeutic agents can be used to treat appetite loss. Forexample, PDE inhibitors can be used to treat appetite loss. The one ormore PDE inhibitors can be a non-selective PDE inhibitor, a PDE-1selective inhibitor, a PDE-2 selective inhibitor, a PDE-3 selectiveinhibitor, a PDE-4 selective inhibitor, a PDE-5 selective inhibitor, aPDE-10 selective inhibitor, or any combination thereof. The methods canalso comprise one or more PDE inhibitors wherein the one or more one ormore PDE inhibitors can be a selective PDE inhibitor. The methods canalso comprise one or more PDE inhibitors wherein the one or more PDEinhibitors can be a non-selective PDE inhibitor that can be amethylxanthine derivative. The methods can also comprise methylxanthinederivative that can be caffeine, theophylline, doxophylline,cipamphylline, neuphylline, pentoxiphylline, or diprophylline. Themethods can also comprise the methylxanthine derivative that can betheophylline. The methods can also comprise a PDE 1 inhibitor can bevinpocetine, compound KS505a, bepril, flunarizine, amiodarone,zaprinast, 8-methoxymethyl IPMX, SCH 51866, Nimodipine, or IC224. Themethods can also comprise a PDE 2 inhibitor that can be EHNA. Themethods can also comprise a PDE 3 inhibitor that can be enoximone,milrinone (Primacor), amrinone, cilostamide, cilostazol (Pletal),trequinsin, inamrinone, anagrelide, pimobendan, lixazinone, ordihydro-pyridazinone. The methods can also comprise a PDE 4 inhibitorthat can be mesembrine, rolipram, ibudilast, roflumilast (Daxas),cilomilast (Airflo), piclamilast, luteolin, drotaverine, ordenbufylline. The methods can also comprise a PDE 5 inhibitor that canbe sildenafil, tadalafil, vardenafil, udenafil and avanafil,dipyridamole, icariin, 4-Methylpiperazine, Pyrazolo Pyrimidin-7-1,cilomilast, or zaprinast. The methods can also comprise a PDE6-selectiveinhibitors that can be zaprinast, dipyridamole, vardenafil, ortadalafil. The methods can also comprise a PDE7-selective inhibitorsthat can be quinazoline type PDE7 inhibitor, dipyridamole, orthiadiazole. The methods can also comprise a PDE8-selective inhibitorsthat can be dipyridamole. The methods can also comprise a PDE9-selectiveinhibitors can be zaprinast. The methods can also comprise a PDE 10inhibitor that can be papaverine, OMS824 (from Omeros Corporation),and/or PF-2545920 (from Pfizer). The methods can also comprise aPDE11-selective inhibitors that can be tadalafil, zaprinast, ordipyridamole.

The methods can further comprise administering to the subject one ormore additional therapeutic agents, wherein the one or more additionaltherapeutic agents can comprise riociguat given or present in an amountselected from a group consisting of: greater than 0.0 μg to 1 μg, 0.5 μgto 2 μg, 1.5 μg to 3.0 μg, 2.5 μg to 10 μg, 5 μg to 15 μg, 12.5 μg to 30μg, 25 μg to 50 μg, 40 μg to 80 μg, 60 μg to 100 μg, 90 μg to 120 μg,110 μg to 130 μg, 125 μg to 150 μg, 140 μg to 180 μg, 170 μg to 200 μg,200 μg to 230 μg, 215 μg to 240 μg, 235 μg to less than 250 μg, and lessthan 250 μg, and greater than about 0.0 μg to about 1 μg, about 0.5 μgto about 2 μg, about 1.5 μg to about 3.0 μg, about 2.5 μg to about 10μg, about 5 μg to about 15 μg, about 12.5 μg to about 30 μg, about 25 μgto about 50 μg, about 40 μg to about 80 μg, about 60 μg to about 100 μg,about 90 μg to about 120 μg, about 110 μg to about 130 μg, about 125 μgto about 150 μg, about 140 μg to about 180 μg, about 170 μg to about 200μg, about 200 μg to about 230 μg, about 215 μg to about 240 μg, andabout 235 μg to less than 250 μg.

The methods can further comprise administering to the subject one ormore additional therapeutic agents, wherein the one or more additionaltherapeutic agents can comprise theophylline given or present in anamount selected from a group consisting of: less than 45 mg, 30 mg, 15mg, 10 mg, 5 mg, 1 mg, 500 μg, 250 μg, 120 μg, 80 μg, 40 μg, or 20 μgand less than about 45 mg, about 30 mg, about 15 mg, about 10 mg, about5 mg, about 1 mg, about 500 μg, about 250 μg, about 120 μg, about 80 μg,about 40 μg, or about 20 μg.

The methods can further comprise administering to the subject one ormore additional therapeutic agents, wherein the one or more additionaltherapeutic agents can comprise forskolin given or present in an amountselected from a group consisting of: less than 500 mg to 450 mg, 475 mgto 425 mg, 435 mg to 400 mg, 415 mg to 300 mg, 325 mg to 250 mg, 275 mgto 150 mg, 200 mg to 100 mg, 135 mg to 80 mg, 95 mg to 65 mg, 75 mg to50 mg, 60 mg to 40 mg, 45 mg to 25 mg, 30 mg to 20 mg, 15 mg to 5 mg, 10mg to 2.5 mg, 3.5 mg to 1 mg, and 2 mg to greater than 0 mg, and lessthan about 500 mg to about 450 mg, about 475 mg to about 425 mg, about435 mg to about 400 mg, about 415 mg to about 300 mg, about 325 mg toabout 250 mg, about 275 mg to about 150 mg, about 200 mg to about 100mg, about 135 mg to about 80 mg, about 95 mg to about 65 mg, about 75 mgto about 50 mg, about 60 mg to about 40 mg, about 45 mg to about 25 mg,about 30 mg to about 20 mg, about 15 mg to about 5 mg, about 10 mg toabout 2.5 mg, about 3.5 mg to about 1 mg, and about 2 mg to greater than0 mg.

Any combination of riociguat, theophylline, and/or forskolin can begiven to a subject. In certain cases, a particular combination ofriociguat, theophylline, and/or forskolin can exhibit synergisticeffects compared to when treating with riociguat, theophylline, and/orforskolin alone. In other cases, a particular combination of riociguat,theophylline, and/or forskolin can exhibit synergistic effects comparedto when treating with riociguat, theophylline, and/or forskolin inpairs. The methods can further comprise administering to the subject oneor more additional therapeutic agents, wherein the one or moreadditional therapeutic agents can comprise: (a) riociguat given orpresent in an amount selected from a group consisting of: greater than0.0 μg to 1 μg, 0.5 μg to 2 μg, 1.5 μg to 3.0 μg, 2.5 μg to 10 μg, 5 μgto 15 μg, 12.5 μg to 30 μg, 25 μg to 50 μg, 40 μg to 80 μg, 60 μg to 100μg, 90 μg to 120 μg, 110 μg to 130 μg, 125 μg to 150 μg, 140 μg to 180μg, 170 μg to 200 μg, 200 μg to 230 μg, 215 μg to 240 μg, 235 μg to lessthan 250 μg, and less than 250 μg, and greater than about 0.0 μg toabout 1 μg, about 0.5 μg to about 2 μg, about 1.5 μg to about 3.0 μg,about 2.5 μg to about 10 μg, about 5 μg to about 15 μg, about 12.5 μg toabout 30 μg, about 25 μg to about 50 μg, about 40 μg to about 80 μg,about 60 μg to about 100 μg, about 90 μg to about 120 μg, about 110 μgto about 130 μg, about 125 μg to about 150 μg, about 140 μg to about 180μg, about 170 μg to about 200 μg, about 200 μg to about 230 μg, about215 μg to about 240 μg, and about 235 μg to less than 250 μg; (b)theophylline given or present in an amount selected from a groupconsisting of: less than 45 mg, 30 mg, 15 mg, 10 mg, 5 mg, 1 mg, 500 μg,250 μg, 120 μg, 80 μg, 40 μg, or 20 μg and less than about 45 mg, about30 mg, about 15 mg, about 10 mg, about 5 mg, about 1 mg, about 500 μg,about 250 μg, about 120 μg, about 80 μg, about 40 μg, or about 20 μg;and (c) forskolin given or present in an amount selected from a groupconsisting of: less than 500 mg to 450 mg, 475 mg to 425 mg, 435 mg to400 mg, 415 mg to 300 mg, 325 mg to 250 mg, 275 mg to 150 mg, 200 mg to100 mg, 135 mg to 80 mg, 95 mg to 65 mg, 75 mg to 50 mg, 60 mg to 40 mg,45 mg to 25 mg, 30 mg to 20 mg, 15 mg to 5 mg, 10 mg to 2.5 mg, 3.5 mgto 1 mg, and 2 mg to greater than 0 mg, and less than about 500 mg toabout 450 mg, about 475 mg to about 425 mg, about 435 mg to about 400mg, about 415 mg to about 300 mg, about 325 mg to about 250 mg, about275 mg to about 150 mg, about 200 mg to about 100 mg, about 135 mg toabout 80 mg, about 95 mg to about 65 mg, about 75 mg to about 50 mg,about 60 mg to about 40 mg, about 45 mg to about 25 mg, about 30 mg toabout 20 mg, about 15 mg to about 5 mg, about 10 mg to about 2.5 mg,about 3.5 mg to about 1 mg, and about 2 mg to greater than 0 mg.

The one or more therapeutic agents can be an effective amount of one ormore members of the hedgehog signaling pathway. For example, the methodscan comprise administration of an effective amount of the one or moreexogenous members of the hedgehog signaling pathway. The methods canalso comprise activating expression of an effective amount of one ormore members of the hedgehog signaling pathway. The activatingexpression of an effective amount of one or more members of the hedgehogsignaling pathway can be effectuated by genetic manipulation of one ormore genes responsible for the expression of one or more members of thehedgehog signaling pathway. The activating expression of an effectiveamount of one or more members of the hedgehog signaling pathway can alsobe effectuated through a therapeutic agent. The therapeutic agent candirectly affect the levels of one or more members of the hedgehogsignaling pathway. The therapeutic agent can indirectly affect thelevels of one or more members of the hedgehog signaling pathway.

The one or more therapeutic agents or composition comprising one or moretherapeutic agents can be suitable for administration by a methodsselected from a group consisting of: oral administration, transmucosaladministration, buccal administration, inhalation administration,intranasal administration, parental administration, intravenousadministration, subcutaneous administration, intramuscularadministration, sublingual administration, transdermal administration,and rectal administration. Because of the ease of use, the one or moretherapeutic agents or composition comprising one or more therapeuticagents can be suitable for oral administration, inhalationaladministration, intranasal administration, or any combination thereof.

The one or more therapeutic agents can comprise one or more cGMPactivators, one or more cAMP activators, or any combination thereof.

The methods can further comprise one or more cGMP activators, whereinthe one or more cGMP activators can be selected from a group consistingof 3-(5′-hydroxymethyl-2′-furyl)-1-benzylindazole (YC-1), YC-1derivatives, anthranilic acids derivatives, ataciguat (HMR1766),benzydamine analogs, CFM1517, A-350619, nitrovasodilators, molsidomine,nitroxyl (HNO), BAY 41-2272, BAY 41-8543, BAY 58-2667, cinaciguat (BAY58-2667), and riociguat (BAY 63-2521). The one or more cGMP activatorscan be riociguat.

The methods can further comprise one or more cAMP activators wherein theone or more cAMP activators can be selected from a group consisting of3-(5′-hydroxymethyl-2′-furyl)-1-benzylindazole (YC-1), glucagon, PDEinhibitors, prostaglandin E1 (PGE1; pharmaceutically known asalprostadil), forskolin, and β-adrenergic agonists. The methods canfurther comprise one or more cAMP activators wherein the one or morecAMP activators can comprise one or more PDE inhibitors and/orforskolin. The methods can further comprise one or more cAMP activatorswherein the one or more cAMP activators can be forskolin.

The one or more therapeutic agents can comprise a non-selective PDEinhibitor, forskolin, and riociguat. The one or more therapeutic agentscan comprise a selective PDE inhibitor, forskolin, and riociguat.Various combinations are also contemplated. For example, the one or moretherapeutic agents can comprise a non-selective PDE inhibitor,theophylline, and riociguat. The one or more therapeutic agents cancomprise a selective PDE inhibitor, theophylline, and riociguat. The oneor more therapeutic agents can comprise a non-selective PDE inhibitorand riociguat. The one or more therapeutic agents can comprise aselective PDE inhibitor and riociguat. The one or more therapeuticagents can comprise theophylline and riociguat. The one or moretherapeutic agents can comprise forskolin and riociguat. The one or moretherapeutic agents can comprise theophylline, forskolin, and riociguat.

Treatment can also vary based on the disease and the severity of theconditions of the subject in need thereof. A physician can determine theappropriate dose of PDE inhibitor or other drugs that can be effectivein treating appetite loss.

Also, the method can further comprise treating with an antiemetic. Forexample, the antiemetic can be selected from 5-HT3 receptor antagonists,Dopamine antagonists, NK1 receptor antagonist, Antihistamines (H1histamine receptor antagonists), Cannabinoids, Benzodiazepines,Anticholinergics, and steroids. The antiemetic can also be is selectedfrom Dolasetron (Anzemet), Granisetron (Kytril, Sancuso), Ondansetron(Zofran), Tropisetron (Setrovel, Navoban), Palonosetron (Aloxi),Mirtazapine (Remeron), Domperidone (Motilium), Olanzapine (Zyprexa),Droperidol, haloperidol, chlorpromazine, prochlorperazine, Alizapride,Prochlorperazine (Compazine, Stemzine, Buccastem, Stemetil, Phenotil),Metoclopramide (Reglan), Aprepitant (Emend), Casopitant, Cyclizine,Diphenhydramine (Benadryl), Dimenhydrinate (Gravol, Dramamine),Doxylamine, Meclizine (Bonine, Antivert), Promethazine (Pentazine,Phenergan, Promacot), Hydroxyzine (Vistaril), Cannabis, Dronabinol(Marinol), synthetic cannabinoids such as Nabilone (Cesamet) or the JWHseries, Sativex, Midazolam, Lorazepam (Ativan), Hyoscine (also known asscopolamine), Dexamethasone (Decadron), Trimethobenzamide, Ginger,Emetrol, Propofol, Muscimol, Peppermint, and Ajwain.

Dosages can be provided as described in the table below.

ANTIEMETIC DOSAGE GUIDELINES CHART ANTIEMETIC SELECTED DOSE SIDE EFFECTSNOTES Anticholinergics 0.3-0.6 mg SC, IM, or IV May be dry mouth,sedation, visual disturbances, Good for patients with motion sicknessSeopalamine repeated 3-4 times daily. memory dysfunction, dysphoria, orundergoing surgery affecting 0.

 mg/24 h topical patch q3d occasionally confusion, vestibular apparatus;apply 4 h prior to (brand dependent) disorientation, hallucinationsexposure Anihistamines Diphenhydramine (Benadryl) 25-50 mg po/IV q6-8 hprn Sedation, dizziness, dry mouth, urinary Diphenhydramine-

-time agent Hydroxyine 25-100 mg IM q4-6 h prn retention, blurred vision[At

HC

), V

 (p

)] 25 mg po tid-qid Class good for patients with motion M

 (A

) 12.5-25 mg po tid-

sickness or undergoing surgery afffecting vesibular apparatusBenzodiazepines Lorazepam (Atrivan) 0.5-2 mg po/IV q4-6 h Sedation,amnesia, confusion, dizziness (dosages up to 4 mg have been used) Mid

0.25-2 mg IV q5 h prn Butyrophe

Droperidol (In

) 0.5-2.5 mg IV q4-6 h Sedation, EPS, dizziness, blood pressureDroperidol-Black box warning-ECG changes, cnfusion, agitation,

monitoring required prior to admin & for 2-3 h

 dose Haloperidol IV-see Haloperidol IV Protocol Opiod-induced N, V; N,V due to bowel obstruction Haloperidol (Haldol) 1-3 mg po q3-6 h 1-5 mgIV/IM q2-6 h Cannabinoids Dronabinol (Marinol) 5-15 mg/m³ po q4-6 hTachycardia, modd changes, dizziness, maximum of 6 doses/d confusion,hallucinations, m

(available as 2.5 mg, 5 mg, and

coordination, amnesia, sedation, 10 mg caps) increased appetiteCorticosteroids Dexamethasone (Decadron) 4 mg po q6-24 h (usually

 24 h) Mood changes, increased appetite, Equivalent Glucocorticoiddosages. (8 mg po-max single dose) psychosia, hyperglycemia (watch inThese are general approximations and 8-20 mg IV q12-24 h diabetes),irritability, leukocytosis, may not apply to all diseases orMethylpredinisone 250-500 mg IV q12-24 h fluid retention (esp. incardiac patients) routes of administration. (Soln-Medrol) Equivalentglucocorticoid doasages: Cortisone—25 mg Hydrocortisone—20 mgPrednisolone—5 mg Prednisone—5 mg Methylprednisolone—1 mgDexamathasone—0.75 mg May take time to work Phenothia

Chlor

 (Thora

) 12.5-25 mg po q4-6 h prn Sedation, EPS,

 side effects, 25-50 mg IM/IV q4-6 h hypotension (IV pro

 and 50-100 mg PR q6-8 h pro

) Prochloperazine (C

) 5-10 mg po IR q4-6 h IV rate not >5 mg/min 10-30 mg po SR q12 hGnerally not recognized in children (max rec daily dose = 40 mg)Effective first-line, currently 5-10 mg IM/IV q4-6 h prn unavailable 25mg PR q12 h Promethazine (Phe

) 12.5-25 mg po/IV/IM q4-6 h prn IV rate not >25 mg/min 25 mg p

 q12 h Thiethylp

 (T

) 10 mg po q8-24 h 10 mg IV q8-24 h Serotonin Antagonists Dolase

 (An

) 100 mg po (1.8 mcg/kg) q24 h prn² Headache (most common), mild Dola

 & G

-Not FDA-approved PONV-12.5 mg IV/IM × 1 sedation, constipation, trans

  indications for more than 1 × dose postop prn elevated LFTs,dizziness, hiccups, Only effective in acute phase, not usefulGranisetron (Kytril) 0.1-1 mg IV/po q12-24 h ECG alterations (rare), EPbeyond 24 h (in terms of chemotherapy) (10 mcg/kg)² reactions (rare) On

 trials in hyperemesis PONV-10-

 mcg/kg IV for 1-3 gravidum, puritus associated with doses seperated byat least 10 min cholestatic jaundice. Ond

 (Zofran) 4-8 mg po q8-24 h All equally effective at equivalent 4-8 mgIV q8-24 h (0.15 mg/kg) doses-cost should be a factor in PONV-1-4 mg IV× 1 post-op prn making a choice Much more effective for vomitting thannausea Substituted Be

Metoclopramide (Reglan) 10 mg po/IV q4-6 h (up to 20 Sedation, diahrrea,EPS, dizziness, Opioid-induced N

 CI in bowel mg used) anxiety, insomnia obstruction, GIB or perforationLow dose (usual d

 10 mg IV q

) Generally not recommended in children High dose 1-3 mg/kg IV q2-6 hTrimethobenzamide (Tigan) Sedation, diahrrea, headache,Trimethobenzamide not recommended EPS (rare) in elderly

indicates data missing or illegible when filed

Business Methods

One or more computers can be utilized in the diagnostic methodsdisclosed herein, such as a computer 800 as illustrated in FIG. 13. Itis contemplated that the computer 800 can be uniquely designed for thetask at hand, e.g., the computer is not a general computer. The computer800 can be used for managing subject and sample information such assample or subject tracking, database management, analyzing biomarkerdata, analyzing cytological data, storing data, billing, marketing,reporting results, or storing results. The computer may include amonitor 807 or other graphical interface for displaying data, results,billing information, marketing information (e.g., demographics), subjectinformation, or sample information. The computer may also include dataor information input 816, 815. The computer may include a processingunit 801 and fixed 803 or removable 811 media or any combinationthereof. The computer can be accessed by a user in physical proximity tothe computer, for example via a keyboard and/or mouse, or by a user 822that does not necessarily have access to the physical computer through acommunication medium 805 such as a modem, an internet connection, atelephone connection, or a wired or wireless communication signalcarrier wave. In some cases, the computer can be connected to a server809 or other communication device for relaying information from a userto the computer or from the computer to a user. In some cases, the usermay store data or information obtained from the computer through acommunication medium 805 on media, such as removable media 812. It isenvisioned that data or diagnoses can be transmitted over such networksor connections for reception and/or review by a party. The receivingparty can be, but is not limited to, an individual, a health careprovider, or a health care manager. For example, a computer-readablemedium includes a medium suitable for transmission of a result of ananalysis of a biological sample, such as a level of one or morebiomarker. The medium can include a result regarding a diagnosis ofhaving a taste or smell disorder for a subject, wherein such a result isderived using the methods described herein.

Sample information can be entered into a database for the purpose of oneor more of the following: inventory tracking, assay result tracking,order tracking, subject management, subject service, billing, and sales.Sample information may include, but is not limited to: subject name,unique subject identification, subject-associated medical professional,indicated assay or assays, assay results, adequacy status, indicatedadequacy tests, medical history of the subject, preliminary diagnosis,suspected diagnosis, sample history, insurance provider, medicalprovider, third party testing center or any information suitable forstorage in a database. Sample history may include but is not limited to:age of the sample, type of sample, method of acquisition, method ofstorage, or method of transport.

The database can be accessible by a subject, medical professional,insurance provider, third party, or any individual or entity grantedaccess. Database access may take the form of electronic communicationsuch as a computer or telephone. The database can be accessed through anintermediary such as a customer service representative, businessrepresentative, consultant, independent testing center, or medicalprofessional. The availability or degree of database access or sampleinformation, such as assay results, may change upon payment of a fee forproducts and services rendered or to be rendered. The degree of databaseaccess or sample information can be restricted to comply with generallyaccepted or legal requirements for patient or subject confidentiality.

Examples Example 1: IL-6 in Hyposmia

Objective:

To determine IL-6 levels in biological fluids of patients with hyposmia.

Study Design:

This is a retrospective clinical study of patients who were evaluatedfor hyposmia.

Methods:

IL-6 was measured in plasma, urine, saliva, and nasal mucus in 59patients with hyposmia of several etiologies and compared with levelsmeasured in normal subjects. Measurements were made by use of aspectrophotometric ELISA assay.

Results:

IL-6 was present in all biological fluids studied. IL-6 levels in nasalmucus were greater than in any other biological fluid in both normalsubjects and patients with hyposmia. Levels in patients with hyposmiawere significantly greater than in normal subjects. IL-6 was selectivelyhigher in nasal mucus in patients with hyposmia, for example, hyposmiafollowing an influenza-like illness [post-influenza-like hyposmia andhypogeusia (PIHH)], in patients with burning mouth syndrome (BMS) and inpatients with hyposmia following head injury.

Conclusion:

Elevated IL-6 in patients with hyposmia compared to normal subjects isreported herein. Since IL-6 is a pro-inflammatory cytokine, thesechanges can relate to local or systemic inflammatory processes whichplay roles either as a cause of or as a result of the pathologicalprocesses associated with hyposmia.

Introduction

Loss of smell (hyposmia) can be a symptom reflective of multiple chronicdisease processes involving multiple organ systems including endocrine,vitamin, trace metal, metabolic, neurological, neurodegenerative,hematological, immunological and other organ systems. Hyposmia canreflect both local changes in the oral or nasal cavities affectingolfactory receptors, in the nerves connecting receptors to the brain orin the brain itself. The systemic changes associated with the majorpathologies noted above can include hyposmia as a major symptom.

This study attempts to understand the multiple pathologies responsiblefor initiation and perpetuation of hyposmia by studying changes insecretions of the multiple organ systems in which hyposmia occurs.Specific biochemical moieties are associated with hyposmia onset andtheir replacement has corrected this symptom. For example, lack ofthyroid hormone can induce hypothyroidism with its associated systemicsymptoms, one of which can be hyposmia; administration of thyroidhormone can correct the systemic symptoms of hypothyroidism and theassociated hyposmia. Zinc deficiency can induce multiple systemicsymptoms and hyposmia which can be manifested by decreased gustin[carbonic anhydrase (CA) VI] secretion; administration of zinc ion tozinc deficient patients can correct both these systemic symptoms and theassociated hyposmia associated with increased CA VI secretion.

The multiple biochemical moieties of these diverse organ systems whichcorrect hyposmia in these various pathologies can be growth factorswhich stimulate olfactory epithelial stem cells to initiate maturationand renewal of the sensory cells responsible for normal olfaction tooccur.

Olfaction is a complex process comprised of multiple component partsincluding receptors, nerves and brain. The local and systemic componentsof this complex process have not been fully explored. Cell signalingprocesses can be critical in any complex sensory system such asolfaction and can involve adenylyl cyclases, sonic hedgehog andcytokines. Here, levels of IL-6 in patients with hyposmia areinvestigated since no prior studies of this type among these patientshave been reported.

IL-6, a proinflammatory cytokine, can be over produced in a spectrum ofclinical illnesses and conditions including cardiovascular disease,osteoporosis, arthritis, Type II diabetes, renal disease, hepatitis,schizophrenia, preeclampsia, various neoplasms, periodontal disease,frailty, stress and functional decline. In these conditions, increasedIL-6 can be found in blood plasma. IL-6 can be increased in both plasmaand ventricular fluid following acute but not chronic head injury.Increased IL-6 can be found in cerebrospinal fluid following traumaticbrain injury and can trigger nerve growth factor secretion inastrocytes. Increased IL-6 can be found in blood plasma of patients withpersistent sciatic pain and IL-6 mRNA can be increased in rat spinalcord following peripheral nerve injury. Increased IL-6 can be found inplasma and in saliva of some patients with burning mouth syndrome (BMS);no IL-6 differences were reported in these patients with and withoutassociated depression and perceived pain. However, stress hormones canregulate IL-6 expression in various ovarian carcinoma cells through aSrc-dependent mechanism. Both specific and nonspecific factors canelicit changes in IL-6 in several biological fluids in several diseaseprocesses including neurological, inflammatory, and psychologicalstress.

To evaluate IL-6 in olfaction, IL-6 levels were investigated in plasma,urine, parotid saliva and nasal mucus among patients with hyposmia andwere compared to similar measurements obtained in a group of normalsubjects.

Methods

Subjects:

Subjects of the study were 59 patients, 26 men, 33 women, age 10-86 y,54±2 y (Mean±SEM) who presented with various degrees of smell loss.Diagnoses of these patients included 24 with post-influenza-likehyposmia and hypogeusia (PIHH), seven with allergic rhinitis, seven withcongenital smell loss, six with hyposmia related to idiopathic causes,five with head injury, four with drug induced hyposmia, three withphantageusia and hyposmia and three with hyposmia and BMS. All patientshad loss of smell as manifested by subjective statements and byolfactometry measurements in which impaired smell function wasdetermined in each patient. Olfactometry was performed usingpsychophysical techniques with four odorants (pyridine, nitrobenzene,thiophene and amyl acetate). These techniques have been validated byperformance in a double-blind clinical trial. Olfactory impairment wasdetermined by impaired detection thresholds (DT) and/or recognitionthresholds (RT) (elevated above normal) and/or decreased magnitudeestimation (ME) levels (below normal levels) for one or more of the fourodorants.

By use of these techniques, smell loss was confirmed in each patientwith 12 patients exhibiting Type I hyposmia (the most severe form ofhyposmia with RTs=0 and ME=0 for all patients for all odors), 44patients with Type II hyposmia (the next most severe form of hyposmiawith DTs, RTs and MEs<normal for all patients) and 3 patients exhibitingType III hyposmia (the least severe form of hyposmia with DTs andRTs=normal but MEs<normal).

Subjects of this study also included eight normal volunteers 4 men, 4women, age 39-76 y, 60±8 y. All normal subjects were healthy and nottaking any prescribed medications. All volunteers had normal smellfunction by subjective statements and by normal olfactometry.

Procedures:

At initial clinical evaluation, blood plasma was collected from eachpatient by venipuncture, placed in ice into tubes containing 100 μl ofzinc free heparin, centrifuged at 3000 rpm for 10 min, the plasmaremoved and stored at −20° C. until assayed. Urine from each patient wascollected over a 24-hour period in timed relationship to collection ofblood plasma. Urine volume was measured and a 20 ml aliquot was storedat 4° C. until assayed. Parotid saliva was collected from each patientimmediately after blood collection by placement of a Lashley cup overStensen's duct with lingual stimulation with reconstituted lemon juice(Borden, Real Lemon, Stamford, Conn.). Saliva was collected in ice inplastic tubes over an 8-12 min period. Samples were stored at −20° C.until assayed. Nasal mucus was collected from each patient directly fromthe nasal cavity in 50 ml wide mouth plastic tubes over a period oftwo-five days in timed relationship to collection of blood, urine andsaliva. After each daily collection nasal mucus was stored at 4° C.After total collection nasal mucus was transferred to plastic centrifugetubes, centrifuged at 18K-20K×g for 40-55 min, the supernatanttransferred to plastic PCR tubes and stored at −20° C. until assayed.

Similar collections of blood, urine, saliva and nasal mucus were alsoobtained from each normal volunteer.

IL-6 was measured by a spectrophotometric 96 plate ELISA assay obtainedfrom R&D Systems (Minneapolis, Minn.). Tests were employed following themanufacturer's directions. Since measurements of IL-6 in nasal mucuswere not previously performed various sample dilutions were developed toperform the assay. These studies reflect all measurements of IL-6 inthese biological fluids made among patients.

All measurements were made without reference to origin of any collectedsample. After all measurements were completed, values were matched withpatients' records, sorted by diagnosis and compared to results obtainedin normal subjects. Mean±SEM were determined for each patient diagnosticcategory and compared to similar results in normals. Differences weredetermined by Student t test with p<0.05 considered significant.Analysis of variance among patient diagnosis, smell loss type (I, II,III) and IL-6 levels in each biological fluid studied was performed withp<0.05 considered significant.

Results

Levels of IL-6 were measured in all biological fluids studied.Comparison of IL-6 levels in each biological fluid was compared betweenpatients and normals. Patients demonstrated large, consistent andsignificant differences in IL-6 levels (Table 1). IL-6 in plasma,saliva, and nasal mucus in patients was significantly higher than innormals. Mean nasal mucus levels in patients were 2.6 times that innormals, mean saliva levels were 1.9 times that in normals and meanplasma levels were 7.9 times that in normals.

Comparison of IL-6 among patients categorized by etiology of loss withnormals demonstrated that mean plasma IL-6 was significantly higher inall patients compared to normal controls; the highest level was found inBMS, the next in head injury, the third highest in PIHH and the lowestin patients with allergic rhinitis (Table 2). Mean urine IL-6 inpatients was similar to normals in all patient categories exceptcongenital hyposmia in whom levels were significantly lower than innormal controls. Mean saliva IL-6 was significantly above normalcontrols in patients with BMS, head injury and PIHH with the highestlevel in BMS. Mean nasal mucus IL-6 was elevated in patients with headinjury, BMS, allergic rhinitis, phantageusia and PIHH but significantlyso only in patients with BMS and PIHH. IL-6 levels in nasal mucus werehighest in patients with head injury and BMS.

Comparative analysis of IL-6 levels in normal controls in plasma, urine,saliva and nasal mucus revealed a specific hierarchy (Table 1) differentfrom that found in patients. Levels of IL-6 in nasal mucus were higherthan in any other biological fluid being over 10 times that found inurine, saliva or in blood plasma. Levels were next highest in urine,then saliva and lowest in plasma. The ratio of nasal mucus:plasma was97:1, of nasal mucus:saliva 34:1 and nasal mucus:urine 9:1.

Comparative analysis of IL-6 levels in patients also yielded a hierarchyof levels but with a somewhat different set of ratios than that found innormals. The highest level of IL-6 was also found in nasal mucus whichwas over 30 times the levels found in saliva, urine or in plasma. Thenext highest levels were found in plasma and urine (levels were similar)and the lowest level in saliva. The ratio of nasal mucus:plasma was 31:1about ⅓ that found in normals, nasal mucus:saliva was 52:1, about 1½times the ratio in normals and nasal mucus:urine was 32:1, about 3½times the ratio found in normals.

There were no significant differences among IL-6 levels in plasma,saliva or nasal mucus with smell loss type and patient diagnosis.

Discussion

The present study is the first to demonstrate IL-6 elevations amongpatients with hyposmia. If these findings were to relate to similarresults found in rheumatoid arthritis (RA) then elevated IL-6 could beconsidered a causal factor for initiation of hyposmia reflective oflocal and/or systemic immunological and/or inflammatory changes inblood, saliva or nasal mucus. This hypothesis is consistent with findingsmell loss among patients with inflammatory RA. Among patients withhyposmia, chronic lymphocytic inflammation can be found in nasal mucousmembranes of patients with PIHH. Elevated IL-6 can be found in nasallavage fluid from patients with naturally acquired viral rhinitis.Paravirus and other viruses can be found in turbinate epithelial cellsof patients with post viral olfactory dysfunction. Manifestation ofherpes virus infection can be found in olfactory bulb neurons in mice aslong as 200 days after they were initially experimentally infected aswell as in astrocytes in the suspected portal of entry. However,histological changes which may occur in the olfactory epithelium,transmitting nerves or in the brain under these conditions have not beeninvestigated. Treatment of RA with IL-6 inhibitors has been associatedwith diminution of both inflammation and IL-6 elevation. If IL-6elevation in hyposmic patients were related to the cause of theirpathology then treatment with IL-6 inhibitory drugs might be associatedwith improvement of their smell function.

Elevation of many substances locally or systemically can inhibit smellfunction including zinc, cadmium, drugs of several types, and severalother chemical moieties. Elevated IL-6 could act as an endogenoussubstance regulating olfactory neuronal activity because it can regulateneuronal and glial cell activity. Thus, IL-6 elevations among patientswith hyposmia and chronic head injury may relate to neurological as wellas to inflammatory changes.

Finding elevated levels of IL-6 in both plasma and in saliva in somepatients with BMS suggests not only a response to an inflammatoryprocess but also a possible neurological process as well. Suggestion ofa neurological rather than an inflammatory mechanism responsible for thepyrosis in BMS is consistent with the lack of obvious signs of oralinflammation among these patients. BMS can be considered a trigeminalsmall fibre neuropathy and treatment with an antioxidant, GABAergicdrugs or repetitive transcranial magnetic stimulation can be used toalleviate this condition.

Results of the present study also illustrate that IL-6 levels in nasalmucus are higher than those in plasma, urine or saliva. This appears tobe the first direct comparison of IL-6 levels in these biological fluidsand the first demonstration that levels of IL-6 in nasal mucus inpatients with hyposmia and in normal subjects are increased relative tothat in plasma, urine or saliva. This finding is logically consistentwith the abundance of microbial and antimicrobial agents normallypresent in nasal mucus. Active inflammatory agents in nasal mucus caninclude bacteria, viruses, fungi, and other substances includinghistamine whereas anti-inflammatory agents found can include lysozyme,lactoferrin and albumin. However, contrary to this supposition, thehighest level of IL-6 in nasal mucus reported here was not in patientswith allergic rhinitis in which these agents might be expected to bemost active but in patients with head injury and BMS in whom no activelocal nasal inflammatory process presumably occurs although both patientgroups exhibit hyposmia.

Possible mechanism(s) of the relationship(s) of IL-6 signaling to lossof smell are multiple. IL-6 can be part of a complex and sophisticatedsignaling system which plays multiple roles in body metabolism. IL-6 canbe an inflammatory cytokine which drives acute phase proteins includingC-reactive protein and fibrinogen, both proteins induced by systemicinflammation. It can be a factor in differentiation of B cells intoantibody producing plasma cells. It can influence NF-κB andATP-ubiquitin-dependent proteolytic pathways, it can activate TNF-α andthereby activate apoptotic pathways which could directly inhibit smellfunction. Neuropoietin, an IL-6 related cytokine which affects signalingthrough ciliary neurotrophic factor receptor, could directly inhibitsmell function since inhibition of several ciliary factors have inducedsmell loss in patients with Kartagener's and Bardet-Biedl syndromes.Patients with Castleman's disease can overproduce IL-6 and treatmentwhich inhibits either IL-6 or IL-6 receptor activity can alleviatesymptoms of the disease. 11-6 deficient mice are incapable of mountingan inflammatory response. After binding to its receptor, the IL-6receptor complex activates gp 130 signaling in cells that would notnormally express IL-6 receptor, a mechanism that can play a role inpathophysiology of chronic inflammatory disorders.

These results suggest that both specific and nonspecific factors mayincrease IL-6 in both acute and chronic disease processes. Theseprocesses can include neurological and inflammatory processes andprocesses involving psychological stress. Indeed, stress hormones canregulate IL-6 expression in various ovarian carcinoma cells through aSrc-dependent mechanism.

This is the first study of any type in which IL-6 measurements wereobtained and compared in patients with chronic disease processes inseveral biological fluids (plasma, urine, saliva and nasal mucus) in asimilar timed based study. These results offer an insight into thesignaling processes present among some patients with hyposmia which mayinfluence some of the complex processes responsible for their sensorychanges.

TABLE 1 IL-6 IN PLASMA, URINE, PAROTID SALIVA AND NASAL MUCUS INPATIENTS WITH HYPOSMIA AND IN NORMAL SUBJECTS NORMALS PATIENTSBIOLOGICAL FLUIDS IL-6 (8) IL-6 (59) PLASMA 0.12 ± 0.03* 0.95 ± 0.10^(a)URINE 1.26 ± 0.41  0.92 ± 0.17^(a) SALIVA 0.30 ± 0.01  0.57 ± 0.05^(a)NASAL MUCUS 11.6 ± 0.50  29.7 ± 3.80^(a) IL-6 (pg/ml) *Mean ± SEM ( )Subject number ^(a)p < 0.001 with respect to normals

TABLE 2 IL-6 IN PLASMA, URINE, PAROTID SALIVA AND NASAL MUCUS INPATIENTS WITH HYPOSMIA Burning Post Mouth Etiology Influenza AllergicCon- Idio- Head Drug Phanta- Syndrome Biological (PIHH) Rhinitisgentital pathic Injury Induced geusia (BMS) Normal Fluid: (24) (7) (7)(6) (5) (4) (3) (3) (6) Plasma 1.03 ± 0.15 0.62 ± 0.12 0.72 ± 0.15 1.03± 0.15 1.47 ± 0.56 0.70 ± 0.1 0.56 ± 0.08 2.20 ± 0.60 0.12 ± 0.03

Urine 1.22 ± 0.38 0.71 ± 0.16 0.29 ± 0.06 1.00 ± 0.40 0.83 ± 0.26 0.78 ±0.26 0.44 ± 0.21 0.90 ± 0.50 —

Saliva 0.51 ± 0.05 0.39 ± 0.06 0.59 ± 0.14 0.55 ± 0.07  0.68 ± 0.18^(d)0.53 ± 0.05 0.45 ± 0.13 1.40 ± 0.70 0.34 ± 0.01

Nasal 29.7 ± 5.2 39.5 ± 18.2 19.6 ± 8.3 13.6 ± 4.7 54.4 ± 23.7 10.8 ±4.0 31.5 ± 23.0  50.9 ± 11.5^(b) 11.6 ± 0.5 Mucus

*Mean ± SEM ( ) Subject number Compared to normal ^(a)p < 0.001 ^(b)p <0.005 ^(c1)p < 0.01 ^(d1)p < 0.02 Compared to PIHH ^(b11)p < 0.005^(e11)p < 0.05 Compared to BMS

indicates data missing or illegible when filed

Example 2: Cytokine Changes in Nasal Mucus and Other Biological Fluidsin Patients with Smell Loss Classified by Age

Cytokine changes in nasal mucus and other biological fluids in patientswith smell loss classified by age.

Background:

Cytokine activity in nasal mucus has not been studied in patients withsmell loss (hyposmia). Cytokines have been reported to change with agewith some known to increase, others to decrease and others not tochange. However, most of these reported changes were observed inrelationship to stimulated activities mainly in various hematologicalsystem functions. Therefore, we performed a survey of cytokine activityin several biological fluids including nasal mucus in patients withhyposmia classified by age.

Methods:

By use of sensitive 96 plate spectrophotometric ELISA techniques IL-1α,IL-1β, IL-1ra, IL-1 RII, IL-2, IL-2R, IL-6, IL-10, IL-18, TNF-α, IFN-βand IFN-γ were measured in nasal mucus, blood plasma, urine and parotidsaliva in 79 subjects with hyposmia at progressive 10 year age groupsfrom <30 y to >70 y.

Results:

IL-1ra levels in nasal mucus were the highest found in any biologicalfluid consistent with the role of this cytokine as an anti-inflammatoryfactor. Cytokines TL-1α, TL-1β and IFN-γ were present in nasal mucusconsistent with their roles as inflammatory factors. These lattercytokines were absent in blood plasma, urine and saliva.

Conclusions:

Cytokine levels in nasal mucus suggest a complex interaction occursbetween proinflammatory and anti-inflammatory cytokines among patientswith hyposmia with the highest levels in the anti-inflammatory cytokineIL-1ra in nasal mucus. Cytokine levels varied with age in complexpatterns. This is the first demonstration of several cytokines in nasalmucus in relationship to other biological fluids.

Introduction

Cytokines are cell signaling moieties activated by specific stimuliwhich lead to many physiological responses. However, these signalingproteins function in such multiple pathways that their specificity maynot be clearly defined. We have been interested in the roles variouscytokines play in patients with smell loss (hyposmia) and have publishedpreliminary data related to changes that occur in cytokines with ageamong these patients who also exhibit anorexia and taste distortions.

However, the pathology associated with hyposmia is quite varied inrelationship to multiple clinical conditions. Most patients develophyposmia following a viral-type infection whereas others develop thissymptom following head injury or associated with systemic and nasalsymptoms of allergic rhinitis. We have attempted to determine somecommon biochemical threads underlying these diverse pathologies and inso doing we and others before us determined that smell loss has beenattributed to changes in secretions from multiple organ systemsincluding decreased levels of trace metals and vitamins, treatment withvarious therapeutic drugs and associated with various pathologicalconditions, including diabetes, other endocrine disorders, neurologicaldisorders and liver disease. In an effort to define these putativecommon pathological threads underlying these various pathologies weundertook systematic studies of the multiple biochemical parametersputatively responsible for loss of smell function. To perform thesestudies we evaluated levels of trace metals in blood plasma and cyclicnucleotides in saliva and nasal mucus. These studies revealed that manypatients with hyposmia exhibited lower than normal levels of zinc intheir saliva and lower than normal levels of adenylyl cyclases in theirsaliva and nasal mucus.

Because hyposmia involves changes in sensory receptors, nerves and brainit was apparent that changes in cell signaling and thus, in cytokines,were involved in this complex system. For example, inhibition of sonichedgehog secretion initiated loss of taste by inhibiting stem cellstimulation in taste buds which is responsible for growth and maturationof the elegant repertoire of cellular components initiating andmaintaining normal taste function. Because cytokines play such asignificant role in cell signaling we undertook a survey of severalcytokines in blood plasma, urine, saliva and nasal mucus among a groupof patients with hyposmia.

Cytokine levels have been previously reported by many investigators tochange with age. In-vitro production of IL-1β, IL-6, TNF-α and IFN-γ byperipheral mononuclear cells was reported increased in aged compared toyounger human subjects. Stimulated T cells from aged mice compared toyoung mice showed increased production of IFN-γ, decreased IL-2 but nodifferences in IL-4. Leukocytes from elderly humans produced higheramounts of IL-1, IL-6, IL-8 and TNF-α than from younger subjects, therewas a decreased release of IL-2 and soluble IL-2R but IL-2R expressionin the cell surface was not increased in the elderly. No age relateddifferences were observed in absolute amounts of IL-1β and IL-6 afternormalizing for circulatory monocytes and there was no age relateddecline in IL-2. Because of these results changes in cytokine levels byage appeared to be one factor by which changes in hyposmia might occur.

Results of our studies indicated that in patients with hyposmia levelsof the anti-inflammatory cytokine IL-1ra in nasal mucus were higher thanin any other cytokine contrasted with the presence of lesser but stilllarge amounts of nasal mucus proinflammatory cytokines. These resultssuggest that a complex interplay between anti- and proinflammatorycytokines occurs among these patients and may play a role in their smellfunction.

Materials and Methods

Patients:

Subjects were 79 patients who presented to The Taste or smell Clinic,Washington, D.C. with clinical complaints of smell loss. Other thansmell loss patients were well and healthy. Patients were 44 women and 35men, aged 53±5 y (Mean±SEM), range 21-83 y. Studies were approved by theInstitutional Review Board of the Georgetown University Medical Center;all patients gave informed consent to participate in this study.

At initial clinical evaluation blood plasma was obtained by venipunctureand stored at −20° C. until assayed. A 24-hour urine was collected indirect timed relationship to collection of blood plasma; volume wasmeasured and an aliquot stored at −20° C. until assayed. Parotid salivawas collected from each patient immediately after blood collection byplacement of a modified Lashley cup over Stensen's duct with lingualstimulation with reconstituted lemon juice (Borden, Real Lemon,Stamford, Conn.) and stored at −20° C. until assayed. Nasal mucus wascollected using spontaneous nasal discharge over two-five days, aspreviously described. After each daily collection samples were stored at4° C. Samples were transferred to plastic tubes, centrifuged at17K-19K×g for 40-55 min and the supernatant stored at −20° C. untilassayed.

Cytokines and some of their receptors (IL-1α, IL-1β, IL-1ra, IL-1 RII,IL-2, IL-2R, IL-6, IL-10, IL-18, TNF-α, IFN-β and IFN-γ) were measuredby sensitive spectrophotometric 96 plate ELISA assays obtained from R&DSystems (Minneapolis, Minn.). Tests were employed following themanufacturer's directions. Since no prior measurements of cytokines innasal mucus were performed various sample dilutions had to be developedto perform this assay.

All measurements were made without reference to any specific clinicaldata including patient age. After all measurements were completed valueswere matched with patient records and sorted by age. Mean±SEM weredetermined for each cytokine with patients separated into progressiveage groups of <30 y, 31-40 y, 41-50 y, 51-60 y, 61-70 y, and >70 y.Significance of differences was determined by Student t test with p<0.05considered significant.

Results

IL-1α.

Values were obtained only in nasal mucus and saliva (Table 3). Levels ofnasal mucus ranged from 24-92 times levels in saliva. For nasal mucusthere was a small, gradual decrease with age. There was no apparent agerelated relationship observed with age in saliva.

IL-1β.

Values were obtained only in nasal mucus (Table 3). Values in nasalmucus were generally higher than those found for IL-1α. There were noapparent age related relationships observed with age.

IL-1ra.

Values were obtained in each biological fluid (Table 3). Levels in nasalmucus were the highest found in any biological fluid. Levels in nasalmucus ranged from 80 to over 1000 times higher than those in plasmawhich were comparatively the lowest among fluids studied. IL-1ra levelsin nasal mucus were almost 1000 times higher than levels in IL-1α andIL-13. By age there was an inverted U shaped pattern for nasal mucuswith the peak at age 40-49 y. There was a U shaped pattern in salivawith the nadir at a similar age with nasal mucus, 40-49 y.

IL-1 RII.

Values were obtained in each biological fluid (Table 3). Levels in nasalmucus were about 0.1-0.5% levels in plasma but 5-90 times levels insaliva and 2-9 times the level in urine. Levels in nasal mucus wereabout 0.2-0.4% values measured in IL-1ra but 5-17 times levels measuredin IL-1α and varied from 5-17 times higher than levels of IL-1β. By agethere was an inverted U shaped pattern for nasal mucus similar to thatmeasured in IL-1ra with the peak at age 40-49 y and a similar inverted Ushaped pattern in plasma with a peak at a similar age.

IL-2.

At dilutions used for this cytokine values were not obtained in anyfluid.

IL-2R.

Values were measured in all biological fluids (Table 3). Levels in nasalmucus varied from 2%-36% below that measured in plasma, from 2%-20%below that measured in urine but from 5-335 times higher than thatmeasured in saliva. Levels in nasal mucus were lower than those measuredin IL-1α, IL-1β, IL-1ra or IL-1 RII. There was a relative inverted Ushaped pattern with age in nasal mucus with the peak again at age 40-49y.

IL-6.

Values were measured in all biological fluids (Table 4). Levels in nasalmucus were higher than in any other of these biological fluids being3-13 times levels in plasma, from 7-25 times levels in urine and 3-10times levels in saliva. Levels in IL-6 were lower than those in IL-1α,IL-1β, IL-1ra, IL-1 RII and IL-2R. With respect to age levels in nasalmucus increased up to age 30-39 y and decreased thereafter.

IL-10.

Values were measured in nasal mucus, saliva and plasma but not in urine.Levels in nasal mucus were generally higher than in either saliva orplasma except at either end of the age range. Levels in nasal mucusranged from 2-20 times higher than in plasma and 2-8 times higher insaliva. With respect to age there was a gradual increase in nasal mucusuntil age 60-69 y and then a decrease thereafter.

IL-18.

Values were measured in nasal mucus, saliva and plasma but not in urine,as with IL-10. Values in nasal mucus varied with respect to levels inplasma but were generally higher than levels in saliva by as much as afactor of seven. Levels in nasal mucus were higher than in IL-2R, IL-6or IL-10 but lower than in IL-1α, IL-1β, IL-1ra or IL-1 RII. Withrespect to age there was again an inverted U shaped pattern in nasalmucus with a peak at age 50-59 y.

TNF-α.

Values were measured in all biological fluids (Table 4). Levels in nasalmucus were higher than in any of these biological fluids being 3-11times higher than levels in plasma, 7-23 times levels in urine and 7-27times levels in saliva. Levels of TNF-α in nasal mucus were higher thanlevels of IL-6 or IL-10 but lower than in IL-1α, IL-1β, IL-1ra, IL-1 RIIand IL-18. With respect to age there was an approximate U shaped patternin nasal mucus with a nadir at age 40-49 y albeit the lowest level wasat age 60-69 y; highest levels were measured at both ends of the agerange.

IFN-β.

Values were obtained in all biological fluids except for urine. Valuesin nasal mucus were generally similar to levels in plasma but higherthan levels in saliva. Levels in nasal mucus were higher than levels inIL-2R, IL-6, IL-10, IL-18 or TNF-α but lower than levels in IL-1α,IL-1β, IL-1ra and IL-1 RII. Age related values in nasal mucus and salivacannot be evaluated due to multiple missing data but there appears to bean inverted U shaped pattern in plasma with the peak at age 30-39 y.

IFN-γ.

Values were obtained only in nasal mucus. Levels were higher than inIL-2R, IL-6, IL-10 and TNF-α but lower than levels in IL-1α, IL-1β,IL-1ra and IL-1 RII. There can be a U shaped pattern with age with thenadir at age 50-59 y.

All numbers in Table 3 and Table 4 that are within a single cell shouldbe read as one number.

Discussion

These data indicate that multiple cytokines in multiple biologicalfluids are present in patients with hyposmia but levels of each cytokinevary in each fluid. Levels in nasal mucus were generally the highestmeasured in any biological fluid with a specific pattern of activity.This pattern appears related to a specific interplay betweenproinflammatory cytokines (e.g., IL-1α, IL-1β, IL-6, IL-18, TNF-α) andanti-inflammatory cytokines (e.g., IL-1ra, IL-10, IFN-γ) among hyposmicpatients and suggest that while there are multiple etiological factorsresponsible for loss of smell, many of which have no apparentinflammatory component, e.g., following head injury or hypothyroidism,there can be an underlying physiological interplay among these nasalmucus cytokines.

Cytokine changes in nasal mucus suggest this complex interplay betweenproinflammatory cytokines and their competitive inhibitoranti-inflammatory components among patients with hyposmia. Since changesin nasal mucus can and do reflect changes in olfactory function theseresults are relevant to basic mechanisms underlying smell loss in thesepatients. The identities of proinflammatory cytokines in nasal mucus areconsistent with the anatomical and pathological changes of chronicinflammation in the nasal mucus membranes as previously identified amongthese hyposmic patients. However, these results are contrasted withlevels of IL-1ra, the competitive inhibitor of these proinflammatorycytokines, which are much higher in concentration than those of theproinflammatory cytokines suggesting an endogenous protective effectagainst acute or chronic inflammation among these patients. This resultis consistent with treatment in hyposmic patients with theophylline orother phosphodiesterase inhibitors which improve smell function amongthese patients and also inhibiting secretion of TNF-α and otherproinflammatory cytokines.

Cytokines are pleiotropic and redundant molecules with a wide variety offunctions with overlapping activities in several cells. For example,TNF-α was initially considered to have mainly immunomodulatory andproinflammatory effects but more recent data suggest that TNF-α also hassignificant anti-inflammatory properties. On the other hand IL-10inhibits synthesis of proinflammatory cytokines including IL-1, IL-6 andTNF-α by modulating liposaccharide induced fever and similar changes inanimals.

IL-1 is a 17 KD proinflammatory cytokine synthesized from a variety ofcell types associated with disease states or during perturbations suchas immune responses. It is part of a family of cytokines which share aconserved β-trefoil structure which binds to receptors belonging to theIL-1 receptor family. In most instances in which inflammation isactivated IL-1 is the major protagonist. IL-18, usually considered aproinflammatory cytokine, has also been reported to play an antagonisticrole to this activity of IL-1 but this action is still controversial.There is a naturally occurring IL-1 specific receptor antagonist,IL-1ra, which shares 40% amino acid homology with IL-1β, binds to IL-1surface receptors with the same affinity as IL-1, does not possessagonist activity but acts as a competitive inhibitor of IL-1. Studiessuggest that IL-1 plays a key role in triggering the cascade ofinflammatory cellular responses with IL-1ra blocking endogenous ILactivity.

IL-1ra in nasal mucus is the highest secreted cytokine among allbiological fluid cytokines measured and highest among all the nasalmucus cytokines measured. This level in nasal mucus is about 800 timeshigher than the levels of IL-1α, over 400 times higher than the level ofIL-1β, about 30 times the level of IL-1 RII and over 19000 times higherthan the level of TNF-α.

With this context in mind evaluation of results of this study suggests acomplex interplay occurs in nasal mucus in patients with hyposmiabetween proinflammatory cytokines IL-1α, IL-1β, IL-6, IL-18 and TNF-αand their competitive inhibitors IL-1ra, IL-10 and IFN-γ. These resultssuggest a mucosal balance between proinflammatory and anti-inflammatorycytokines among these patients suggesting some control of these elementsin hyposmia. This contrasts with the imbalance between theseproinflammatory and anti-inflammatory cytokines in patients withinflammatory bowel disease in which IL-1 is significantly greater thanIL-1ra which has been related to a novel mechanism of chronic intestinalinflammation in chronic inflammatory bowel disease and the presence ofhyposmia.

The increased proinflammatory cytokines in nasal mucus is consistentwith the anatomical and pathological changes of inflammation in thenasal mucus membranes previously identified among patients with viralrhinitis and among these hyposmic patients. Theophylline treatment,which improved smell function among these patients, also inhibitedsecretion of TNF-α and other proinflammatory cytokines which supportthese observations. Since levels of IL-1ra, the major competitiveinhibitor of these proinflammatory cytokines are much higher than thoseof the proinflammatory cytokines these results suggest an endogenousprotective effect against acute or chronic inflammation occurs amongthese patients.

While the changes observed in this study relate to mucosal changes incytokines released into nasal mucus by cells in nasal epithelial glandsthese changes may also relate in changes in central nervous system andanterior pituitary function. Changes in IL-1β, IL-1ra and IL-10 geneexpression have all been shown to be increased during systemicinflammation in the central nervous system and anterior pituitary. Theseresults suggest that IL-1ra can be secreted by the anterior pituitary asa systemic anti-inflammatory hormone released in response to IL-1β frommultiple system sources consistent with the results we have observedamong hyposmic patients. IL-18 gene polymorphism has also been foundamong patients with allergic diseases.

Changes we measured in cytokine levels with age in each biological fluidare complex. Previous investigators reported that many factors influencecytokine changes in addition to age including caloric restriction,endotoxin presence, oxidative stress and hormonal states. Age changes inTNF-α have been reported to be predictive of insulin resistance. Thus,differences in levels in each biological fluid we studied may reflectnot only differences in each cytokine with age but also other mechanismsrelated to multiple factors not identified in this study. Indeed, themost relevant aspect of this study relates not to age changes but tochanges in cytokines in nasal mucus itself relative to changes in otherbiological fluids as related to patients with hyposmia. With thesecytokine changes in nasal mucus these results suggest a complexinterplay between proinflammatory cytokines and their competitiveinhibitors occurs among patients with hyposmia. Since changes in nasalmucus can and do reflect changes in olfactory function these results arerelevant to the basic mechanism(s) underlying smell loss in this groupof patients. Indeed, antibodies to specific cytokines have beensuccessful in disease treatment.

Among the cytokines measured there is an apparent hierarchy of levelsamong the various biological fluids studied. Nasal mucus IL-1ra is themost prevalent cytokine in any biological fluid studied although thereare significant variations in these measurements. Urinary IL-1ra is themost prevalent urinary cytokine among all urinary cytokines studied.Plasma and saliva IL-1 RII are the most prevalent cytokines among theplasma and saliva levels measured.

Cytokine concentrations found in these biological fluids are relative tomeasurement techniques used. Because these results reflect cytokinelevels under physiological conditions, albeit in patients with hyposmia,it is difficult to compare these results with those previously reportedby most other investigators since they mainly reported age relatedchanges in cytokine activity in hematological or tissue cell function inresponse to specific stimulatory and inhibitory substances. Inamizu, etal. reported macrophage IL-1β production decreased with age whereas inour studies there was no change with age in nasal mucus. Previousinvestigators reported decreased keratinocyte IL-1α production with agewhereas our results show a generalized increase with age in IL-1α ineach biological fluid studied. It is known that IL-1 stimulates IL-1raproduction but the complex changes with age we demonstrate in eithernasal mucus or saliva do not support the observation that IL-1 relatesto increased levels in IL-1ra. IL-2R from older subjects have beenreported to decline with age but in our studies there were increases inplasma, little change in urine and a complex pattern of change in nasalmucus. Beharka, et al. reported that IL-6 production does not increasewith age whereas in our studies IL-6 in plasma increased, particularlyat age 60-69 y, and in urine at age 49-49 y. IL-10 in our studyincreased with age in each fluid whereas Ye, et al. reported age-relateddeclines in IL-10 in brain sections and glial cells in mice. Consistentwith our studies, aged marine CD4⁺ T cells produced more IL-10 than didyoung cells. There were no changes reported in IFN-γ production with agewhereas we reported an increase in nasal mucus levels at age 60-69 y.Variable age related changes in TNF-α and interferon have been reportedby many previous investigators. Changes in cytokine levels with age inseveral other biological fluids have been previously reported; Kawasaki,et al. reported that RANKL and OPG levels decreased in gingivalcrevicular fluid with age and Yamakawa, et al. reported an increase inIL-1β production in murine parotid acinar cells with age and theyreported a decrease in IL-6.

This is the first study in which cytokine levels in several biologicalfluids in patients with hyposmia have been reported and the first inwhich cytokine levels in several biological fluids, measured in neartime to each other, have been reported.

TABLE 3 CHANGES IN HUMAN CYTOKINE LEVELS WITH AGE Age Nasal Nasal Nasaly Mucus Saliva Plasma Urine Mucus Saliva Plasma Urine Mucus SalivaPlasma Urine IL-1α (pg/mL) IL-1β (pg/mL) IL-1

 (pg/mL) <30 201

2.6 0 0 303 0 0 0 15534 14573 198 2534 30-39 203 2.2 0 0 156 0 0 0 5822690

0 373 6099 40-49 135 2.3 0 0 262 0 0 0 111243 77

7 80 746 50-59 149 3.7 0 0 248 0 0 0 64576 17319 262 2875 60-69 121 5.00 0 301 0 0 0 52132 20293 212 2992 >70 147 2.8 0 0 235 0 0 0 52215 25371262 4769 <30

.9 0 0 40 0 0 0 5065 11528 88 1800 30-39 50 .6 0 0 65 0 0 0 18305

908 148 3073 40-49 24 .7 0 0 38 0 0 0 3919 2445 6 506 50-59 33 1.6 0 075 0 0 0 12145 6739 93 1887 60-69 32 1.7 0 0 57 0 0 0 14218 7722 35959 >70 38 1.3 0 0 54 0 0 0 13742 9726 52 2498 IL-1RII (pg/mL) IL-2(pg/mL) IL-2R (pg/mL) <30 674

123 12323 394 0 0 0 0 9 0 467 1019 30-39 1844 59 15338 302 0 0 0 0 27 16808 988 40-49 3003 43 36680 352 0 0 0 0 335 1 939 1698 50-59 1961 3

16495 478 0 0 0 0

1 16 814 1167 60-69 2153 24 21457 365 0 0 0 0 80 19 1418 1177 >70 108740 20257 302 0 0 0 0 27 12 1003 1303 <30 245

4 68 121 0 0 0 0 9 0 107 679 30-39 849 21 1699 52 0 0 0 0 20 11 89 25540-49 1518 20 11143 64 0 0 0 0 188 1 523 454 50-59 1075 13 2311 117 0 00 0 17 10 153 275 60-69 1023 7 2921 66 0 0 0 0 48 18 312 216 >70 288 182684 77 0 0 0 0 15 10 132 71 *Mean †±SEM 0 Values were 0

indicates data missing or illegible when filed

TABLE 4 CHANGES IN HUMAN CYTOKINE LEVELS WITH AGE Age Nasal Nasal Nasaly Mucus Saliva Plasma Urine Mucus Saliva Plasma Urine Mucus SalivaPlasma Urine IL-6 (pg/mL) IL-10 (pg/mL) IL-18 (pg/mL) <30 1.1

0.11 0.08 0.05 0.03 0.52 0.10 0

0 18 175 0 30-39 2.7 0.08 0.10 0.06 0.32 0.48

0.53 0 167 36 187 0 40-49 1.7 0.15 0.19 0.25 0.84 0.44

0.40 0 122 92 195 0 50-59 0.3 0.07 0.07 — 2.47 0.33 0.62 0 405 54 224 060-69 0.7 0.06 0.22 0.04 8.99 1.08 0.48 0 116 117 163 0 >70 0.3 0.060.09 — 0.42 0.53 0.45 0 119 59 338 0 <30 0.6

0.02 0.01 0.01 0.10 0.14 0.01 0 46 10 116 0 30-39 0.14 0.03 0.03 0.010.22 0.10 0.10 0 74 10 62 0 40-49 1.0 0.09 0.09 0.12 0.55 0.03 0.11 0 8027 54 0 50-59 0.1 0.04 0.04 — 0.40 0.01 0.12 0 193 26 90 0 60-69 0.120.03 0.08 0.02 6.80 0.24 0.03 0 41 37 32 0 >70 0.08 0.03 0.03 — 0.020.22 0.0

0 53 32 13

0 INF-α (pg/mL) IFN-β (pg/mL) IFN-γ (pg/mL) <30 11.7

0.8 1.0 0.7 0 0 1584 0 109 0 0 0 30-39 8.9 0.3 3.0 0.5 0 0 2175 0 77 0 00 40-49 5.8 0.

3.0 0.3 1239 8 1690 0 67 0 0 0 50-59 7.3 0.

2.2 0.4 — 160 — 0 55 0 0 0 60-69 2.7 0.4 2.0 0.4 351 6 492 0 121 0 00 >70 16.1 0.6 3.2 0.7 428 15 533 0 63 0 0 0 <30 5.3

0.8 0.1 0.3 0 0 995 0 12 0 0 0 30-39 5.2 0.1 0.7 0.1 0 0 2175 0 8 0 0 040-49 2.2 0.3 0.9 0.1 819 8 1142 0 31 0 0 0 50-59 2.7 0.1 0.8 0.1 — 101— 0 21 0 0 0 60-69 2.7 0.1 0.9 0.3 309 4 382 0

9 0 0 0 >70 6.7 0.3 0.5 0.2 428 15 483 0

3 0 0 0 *Mean †±SEM 0 Values were 0 —No sample obtained ^(a)p < 0.05with respect to age 60-69 y

indicates data missing or illegible when filed

Example 3: IgE and Eosinophil Changes in Hyposmia

Patients with smell loss have multiple clinical and biochemicalcharacteristics which define their pathology. In a recent reanalysis ofdata obtained at The Taste or smell Clinic in Washington, D.C. 28patients were analyzed with taste or smell dysfunction. Each of the 28patients has a significant abnormality in ability to taste or smell.Eight of the 28 patients (29%) have an elevated serum IgE level. Levelsrange from 128-781 kU/L (mean±SEM, 258±82). Four of these patients havea primary diagnosis of post influenza-like hyposmia and hypogeusia(PIHH); four have a primary diagnosis of allergic rhinitis. Patients areseven men, one woman, aged 35-71 y. Five of the 28 patients (18%) havean elevated plasma eosinophil level. Levels range from 3.7-11.9% oftotal white blood cells (mean±SEM, 6.1±2.3%) with eosinophil counts of307-750 cells (mean±SEM, 462±176). Three of these patients have adiagnosis of PIHH, two have a diagnosis of allergic rhinitis. Patientsare four men, one woman, aged 39-71 y. Two have both an elevated IgE andeosinophil count, one man, one woman, both with PIHH, age 39 and 71,respectively. These patients also have low levels of cAMP and cGMP intheir saliva and nasal mucus.

Patients are treated and tested with theophylline to test if restorationof smell function can be restored. A comparison of this subpopulation ofpatients to larger group of patients is performed.

Example 4: Role of Nitric Oxide in Smell Loss

In this example the role of nitric oxide in smell loss is investigated.Phosphodiesterase (PDE) inhibitors may improve smell loss through othermechanisms, such as through nitric oxide (NO). Theophylline, ageneralized PDE inhibitor, may increase nitric oxide (NO) at the sametime that it increases cAMP and cGMP. Patients with hyposmia treatedwith theophylline may not only have increased nasal mucus cAMP and cGMPbut also increased NO. NO through guanylate cyclase produces cGMP, whoseelevation mediates, in part, NO stimulatory effects on smell loss. cGMPcan be 1) degraded by PDE isoforms and 2) can be enhanced by PDEinhibition which maintains its presence.

To investigate this possibility, treatments with alternativepharmaceutical compositions, which may increase nitric oxide production,levels, effective amounts or half-life are administered to patients withhyposmia. Pharmaceutical compositions that are directed towards increasein cGMP and cAMP may also be administered.

Example 5: Cyclic Nucleotides in Saliva

Methods: All studies were performed at The Taste and Smell Clinic,Washington, D.C. between February 2001 and July, 2005 and constitutestudies on consecutive normal subjects and patients. Studies wereapproved by the Institutional Review Board of the Georgetown UniversityMedical Center.

Parotid saliva was collected from 61 normal volunteers, aged 18-75 y[50±5 y (Mean±SEM)]. Normal volunteers were 40 men, aged 23-75 y (51±7y) and 21 women, aged 18-69 y (49±4 y) who were well and healthy,without any acute or chronic disease and were not taking any medication.Parotid saliva was also collected from 253 patients, aged 9-83 y [55±3 y(mean±SEM)] with taste and smell dysfunction. Patients were 104 men, age9-83 y (56±2 y) and 149 women, age 12-79 y (54±2 y).

Smell and taste function tests were obtained in all normal subjects andpatients by use of standard three stimuli, forced choice, staircasefixed design measurements of detection (DT) and recognition (RT)thresholds and magnitude estimation (ME) for four tastants (NaCl forsalt, for sweet, HCl for sour, urea for bitter) and four odorants(pyridine—“dead fish” odor, nitrobenzene—bitter almond odor,thiophene—petroleum odor, and amyl acetate—banana oil odor) previouslydescribed in detail with results confirmed and validated in adouble-blind clinical trial and in the studies of other investigators.Normal subjects exhibited DT, RT and ME within normal range for alltastants and odorants tested.

Patients with taste and smell dysfunction exhibited a variety of sensoryabnormalities secondary to several etiological factors. Etiology ofonset of dysfunction included post viral infections [about 30% ofpatients], post concussive syndrome [about 20%], allergic rhinitis[about 15%], idiopathic causes [about 12%] and several other etiologies.Patient abnormalities of sensory function included loss of taste acuity[elevated DT, RT and ME for two or more tastants in 90% of patients],loss of smell acuity [elevated DT, RT and/or ME for two or more odorantsin 98% of patients], dysgeusia [distortions of taste function includingaliageusia and phantageusia, in 70%] and dysosmia [distortions of smellfunction including aliosmia and phantosmia, in 70%]. More than 85% ofpatients had more than one sensory abnormality.

Saliva was collected in the morning hours with subjects abstaining fromeating or smoking at least two hours prior to collection. Saliva wascollected by placing a modified Lashley cup over Stensen's duct andmaximally stimulating flow by lingual placement of reconstituted lemonjuice (Borden, Tarrytown, N.Y.) at 10 sec intervals. Saliva wascollected continuously over an eight-12 min period until approximately 8ml were present. Flow rate was calculated by obtaining mean fluid weightper time of collection. Saliva was stored at −20° C. until assayed.

cAMP and cGMP were measured by a spectrophotometric colormetric 96 plateELISA technique using kits supplied by R&D Systems (Minneapolis, Minn.).Mean variation of kit standards was ≦5%. Protein was measured byobtaining spectrophotometric absorbance at 215-225 nm and use of theextinction coefficient; in this manner protein in very small samples wasestimated. cAMP and cGMP were expressed in three ways; per ml saliva,per mg protein and per ml flow rate.

To determine methodological reliability cAMP and cGMP were determinedusing several parameters. Duplicates of six saliva samples weredetermined on 20 occasions; the standard deviation of these samplesvaried from 0.007-0.038 for both cAMP and cGMP; mean coefficients ofvariation varied from 1-10% for both moieties with an overall mean of4%. cAMP and cGMP from one subject were determined on 20 separateoccasions over a period of two years; the standard deviation for thesedeterminations for cAMP (in pmol/ml) was 0.29 with a mean coefficient ofvariation of 3%; for cAMP/mg protein standard deviation was 0.13 with amean coefficient of variation of 4%; for cAMP per/ml flow rate standarddeviation was 0.49 with a mean coefficient of variation of 5%; for cGMP(in pmol/ml), standard deviation was 0.02 with a coefficient ofvariation of 6%; for cGMP (in pmol/mg protein), standard deviation was0.007 with a coefficient of variation of 7%; for cGMP (in pmol/ml flowrate), standard deviation was 0.05 with a coefficient of variation of10%.

Mean and SEM for each subject group were calculated. Differences betweengroup means were calculated using Student t tests. Age data arepresented only for the patients since there were sufficient gaps in theages of the normals studied. However, calculation of age changes withthe normals included did not affect the results obtained using only thepatient data.

Results: Salivary cAMP and cGMP in normal subjects

Both cAMP and cGMP are present in parotid saliva in normal subjects inthe detection range of the assay used (Table 5). Salivary cAMP issignificantly higher than cGMP by all methods of determination andvaried from seven-10 times higher (Table 5). Salivary cAMP levels areconsistently higher in women than in men and varied from 25-49% higher(Table 5). There were no differences in flow rate, protein or agebetween men and women (Table 5).

Salivary cAMP and cGMP in Patients with Taste and Smell DysfunctionCompared with Normal Subjects

Both cAMP and cGMP are present in parotid saliva obtained from patientswith taste and smell dysfunction (Table 6). Patients exhibit lower meanconcentrations of both salivary cAMP and cGMP than do normal subjectsbut only cAMP levels are significantly lower (Table 6). These resultsare independent of methods of expression. Concentrations of cAMP wereeight-nine times higher than cGMP (Table 6). Mean salivary flow rate wassignificantly lower in patients than in normals (Table 6).

Salivary cAMP was significantly lower than normal in both men and womenpatients, respectively (Table 7) whereas there were no differences incGMP (Table 7). Mean salivary flow rates were significantly lower amongboth men and women patients compared to normals (Table 7).

Salivary cAMP and cGMP with Respect to Age

Salivary cAMP and cGMP concentrations vary with respect to age (FIGS. 14and 15). While number of subjects is relatively small there is a complexpattern for cAMP over the age range, generally increasing with agereaching a peak at 41-50 y, then decreasing until >70 y when levels 9increased again (FIG. 14). For cGMP there is a similar pattern withmaximum values also reached at 41-50 y, then values decreasingthereafter but, as with cAMP, with a terminal increase at >70 y. ForcAMP and cAMP/protein age differences were significantly differentcomparing ages 31-40 with ages 41-50 (p<0.02, and p<0.05, respectively,t test) and ages 51-60 with ages 41-50 (p<0.05 and p<0.01 respectively,t test). For cGMP and cGMP/protein age differences were significantlydifferent comparing ages 31-40 with ages >70 (p<0.01 and p<0.005,respectively, t test) and ages 61-70 with ages >70 (p<0.05, t test).Salivary protein secretion and flow rate did not change significantlythroughout the aging process (Table 8).

TABLE 5 cAMP and cGMP IN PAROTID SALIVA IN NORMAL SUBJECTS cAMP cGMPFLOW NOR- pmol/mg pmol/min pmol/mg pmol/min PROTEIN RATE AGE MALSpmol/ml protein flow rate pmol/ml protein flow rate mg/dl ml/min y Total2.00 ± 0.19 0.63 ± 0.06 2.17 ± 0.19 0.21 ± 0.02

0.006 ± 0.009

0.23 ± 0.04

3.17 ± 0.18 0.92 ± 0.05 50 ± (61) 5 Men 1.69 ± 0.17 0.53 ± 0.04 1.86 ±0.24 0.22 ± 0.05

0.069 ± 0.015

0.24 ± 0.08 3.17 ± 0.10 0.91 ± 0.02 51 ± (40) 7 Women 2.26 ± 0.31 0.71 ±0.10 2.43 ± 0.18 0.21 ± 0.02

0.066 ± 0.009

0.23 ± 0.02 3.18 ± 0.19 0.93 ± 0.06 49 ± (21) 4

MP and cGMP in parotid saliva in normal subjects. ( ) reflects subjectnumber. Data are presented as Mean ± SEM for each parameter studied. Pvalues (determined by Student t test) are considered significant if<0.05 [^(a)p < 0.001, compared to cAMP respectively].

indicates data missing or illegible when filed

TABLE 6 cAmp and cGMP IN PAROTID SALIVA IN NORMAL SUBJECTS AND INPATIENTS WITH SELL LOSS cAMP cGMP FLOW pmol/mg pmol/min pmol/mg pmol/minPROTEIN RATE AGE pmol/ml protein flow rate pmol/ml protein flow ratemg/dl ml/min y Patients 0.83 ± 0.04^(a) 0.27 ± 0.02^(a) 1.19 ± 0.07^(a)0.16 ± 0.02 0.050 ± 0.007 0.23 ± 0.02 3.10 ± 0.06 0.70 ± 0.02^(a) 55 ±(253) 3 Normals 2.00 ± 0.19  0.63 ± 0.06  2.17 ± 0.19  0.21 ± 0.02 0.066± 0.009 0.23 ± 0.04 3.17 ± 0.18 0.92 ± 0.05  50 ± (61) 5

MP and cGMP in parotid saliva in patients with taste and smellfysfunction and in normal subjects. ( ) reflects subject number. Dataare presented as Mean ± SEM for each parameter studied. P values(determined by Student t test) are considered significant if <0.05[^(a)p < 0.001, with respective to normals].

indicates data missing or illegible when filed

TABLE 7 cAMP and cGMP IN PAROTID SALIVA IN NORMAL MEN AND WOMEN AND MENAND WOMEN WITH SMELL LOSS cAMP cGMP FLOW pmol/mg pmol/min pmol/mgpmol/min PROTEIN RATE AGE pmol/ml protein flow rate pmol/ml protein flowrate mg/dl ml/min y PATIENTS Men (104) 0.90 ± 0.06^(a) 0.28 ± 0.03^(a)1.27 ± 0.13^(c) 0.14 ± 0.20 0.044 ± 0.005 0.20 ± 0.03 3.18 ± 0.09 0.71 ±0.03^(a) 56 ± 2 Women 0.80 ± 0.07^(a) 0.26 ± 0.03^(a) 1.14 ± 0.14^(a)0.17 ± 0.02 0.062 ± 0.009 0.24 ± 0.05 3.05 ± 0.09 0.70 ± 0.03^(b) 54 ±(149) 2 NORMALS MEN (40) 1.69 ± 0.17  0.53 ± 0.04  1.86 ± 0.24  0.22 ±0.05 0.069 ± 0.015 0.24 ± 0.09 3.17 ± 0.10 0.91 ± 0.02  51 ± 7 Women2.26 ± 0.31  0.71 ± 0.10  2.43 ± 0.18  0.21 ± 0.02 0.069 ± 0.009 0.23 ±0.02 3.18 ± 0.19 0.93 ± 0.07  49 ± (21) 4

MP and cGMP in parotid saliva in men and women patients with taste andsmell dysfunction and in normal men and women. ( ) reflects subjectnumber. Data are presented as Mean ± SEM for each parameter studied. Pvalues (determined by Student t test) are considered significant if<0.05 [^(a)p < 0.001 with respective to normal men or women; ^(c)p <0.05 with respect to normal men; ^(b)p < 0.005 with respect to normalwomen].

indicates data missing or illegible when filed

TABLE 8 CHANGES IN PAROTID SALIVA PROTEIN AND FLOW RATE RELATED TO AGEPROT Flow Rate AGE AGE mg/dl ml/min <20 (5) 16 ± 2 2.59 ± 0.41 1.00 ±0.30 21-30 (15) 27 ± 1 2.79 ± 0.17 0.76 ± 0.06 31-40 (23) 36 ± 1 3.27 ±0.14 0.63 ± 0.04 41-50 (46) 45 ± 1 2.99 ± 0.15 0.73 ± 0.05 51-60 (46) 56± 1 3.40 ± 0.14 0.70 ± 0.04 61-70 (37) 66 ± 1 3.08 ± 0.16 0.69 ±0.04 >70 (30) 77 ± 1 2.94 ± 0.17 0.64 ± 0.06 Parotid saliva protein andflow rate related to age. ( ) reflects subject matter. Data arepresented as Mean ± SEM.

Example 6: Decreased Parotid Salivary Cyclic Nucleotides Related toSmell Loss Severity in Patients with Taste and Smell Dysfunction

Methods:

All studies were performed at The Taste and Smell Clinic, Washington,D.C., between February 2001 and July 2005 and constitute studies onconsecutive healthy subjects and patients. Studies were approved by theInstitutional Review Board of the Georgetown University Medical Center.

Parotid saliva was collected from 61 healthy volunteers, aged 18 to 75years (mean±SEM, 50±5 years). The volunteers were 40 men, aged 23 to 73years (51±7 years), and 21 women, aged 19 to 69 years (49±4 years), whowere well and healthy, without any acute or chronic disease, and nottaking any medication. Smell and taste function in each subject waswithin normal limits. Parotid saliva was also collected from 253patients, aged 9 to 83 years (55±3 years), with taste and smelldysfunction. Patients were all those with taste and smell dysfunctionwho had loss of smell. These included 104 men, aged 9 to 83 years (56±2years), and 149 women, aged 12 to 79 years (49±4 years).

Saliva was collected in the morning hours with subjects abstaining fromeating or smoking at least 2 hours before collection. Saliva wascollected by placing a modified Lashley cup over the Stensen duct andmaximally stimulating flow by lingual placement of reconstituted lemonjuice (Borden, Tarrytown, N.Y.) at 10-second intervals. In patients,saliva was collected immediately after completion of sensory tasting.Saliva was collected continuously over an 8- to 12-minute period untilapproximately 8 mL was collected. Flow rate was calculated by obtainingmean fluid weight per time of collection. Saliva was stored at −20° C.until assayed.

Cyclic AMP and cGMP were measured by a sensitive spectrophotometric96-plate enzyme-linked immunosorbent assay technique using kits suppliedby R&D Systems (Minneapolis, Minn.). Mean variation of kit standards wasless than or equal to 5%. Protein was measured by obtainingspectrophotometric absorbance at 215 to 225 nm with the use of theextinction coefficient; in this manner, protein in very small sampleswas estimated. Cyclic AMP and cGMP in picomole/concentration wereexpressed in 3 ways: per milliliter saliva, per milligram protein, andper milliliter flow rate.

To determine methodological reliability, cAMP and cGMP were determinedin several ways. Duplicates of 6 saliva samples were determined on 20occasions; the standard deviation of these samples varied from 0.007 to0.038 for cAMP and 0.007 to 0.038 for cGMP, respectively; meancoefficients of variation varied from 1% to 10% for each moiety. CyclicAMP and cGMP from 1 subject were determined on 12 separate occasionsover a period of 2 years. The standard deviation for thesedeterminations for cAMP (picomoles per milliliter) was 0.29 with a meancoefficient of variation of 3%; for cAMP (picomoles per milligramprotein), 0.13 with a mean coefficient of variation of 4%; for cAMP(picomoles per milliliter flow rate), 0.49 with a mean coefficient ofvariation of 5%; for cGMP (picomoles per milliliter), 0.02 with acoefficient of variation of 6%; for cGMP (picomoles per milligramprotein), 0.007 with a coefficient of variation of 7%; and for cGMP(picomoles per milliliter flow rate), 0.05 with a coefficient ofvariation of 10%.

Smell loss was measured by psychophysical techniques by use of aforced-choice, 3-stimuli, stepwise staircase technique in a fixedcontrolled design. Efficacy of these techniques and results therefromwere previously documented in a double-blind clinical trial. Four odorswere used: pyridine or “dead-fish” odor, nitrobenzene or bitter-almondodor, thiophene or petroleum-based odor, and amyl acetate or banana oilodor. Detection thresholds (DTs), recognition thresholds (RTs), andmagnitude estimation (ME) for each odor were determined in this fixedcontrolled design.

Odors were presented in the order of thiophene, amyl acetate,nitrobenzene, and pyridine. Odors were stored in 60-mL, wide-mouth,screw-capped amber bottles with 12 mL of test solution in each bottle.For each test, each patient was seated at a right angle to the testadministrator and was shielded from any visual contact with the testmaterials. For each test, the patient was required to sniff theheadspace above the solution in each bottle in a sequence of 3 stimuliin succession in a fixed, mixed design. Two of the stimuli wereemollient (water or light mineral oil), and one was emollient withodorant. Each of the 3 solutions was opened and closed in sequence withthe patients sniffing about 2 to 3 cm above the edge of the open bottlefor 2 to 10 seconds. Each sequence of 3 stimuli required 20 to 60seconds, with a rest period of 5 to 20 seconds between each set of 3stimuli.

The patient was required to perform 3 tasks after the presentation ofeach set of 3 stimuli. First, the patient determined which stimulus withodorant was different from the 2 emollients without odorant (to detect adifference among the 3 stimuli); second, the patient described theodorant in the odorant containing stimulus in words, that is,recognizing and describing the character of the odorant; and third, thepatient estimated the intensity of the identified odorant using a scalefrom 1 to 100 (an estimate of magnitude intensity). On this scale, 100was described as the most intense odorant of the odorant type previouslyexperienced under normal conditions within that odor category. Thus, 1was the least intense, 100 was the greatest, and any intensity between 1and 100 was judged accordingly.

Testing always began at what had been previously determined to be theupper limit of normal detection (10⁻⁵ mol/L for each odorant). If thepatient detected and recognized the odorant correctly at thisconcentration, the odorant concentration was decreased stepwise (10⁻⁶,10⁻⁷, 10⁻⁸, and 10⁻⁹ mol/L) until the patient could no longer correctlydetect or recognize any difference among the 3 stimuli. If the patientcould neither detect nor recognize the odorant correctly at 10⁻⁵ mol/L,the odorant concentration was increased stepwise (10⁻⁴, 10⁻³, 10⁻²,10⁻¹, and 100 mol/L and absolute) until the patient could detect andrecognize the odorant correctly. Using this staircase, turnaroundtechnique, odorant concentrations were either increased or decreaseduntil the patient detected and recognized correctly the odorant asdifferent from emollient 2 out of 3 times at 1 concentration and couldnot do so at the next lower or higher concentration. Thus, if thepatient could neither detect nor recognize correctly 10⁻⁵, 10⁻⁴, and10⁻³ mol/L odorant but could both detect and recognize correctly odorantat 10⁻² mol/L, the next stimulus presented was the next lowerconcentration, 10⁻³ mol/L. If the patient could once again neitherdetect nor recognize correctly the stimulus at 10⁻³ mol/L, the stimulusat 10⁻² mol/L was once again presented. If the patient once againdetected and correctly recognized the stimulus at 10⁻² mol/L, this partof the test was completed because the patient gave 2 incorrect responsesat 1 stimulus concentration and 2 correct responses at the next higherconcentration. The odorant concentration at 10⁻² mol/L was consideredthe DT and RT.

Magnitude estimation determination began in healthy subjects at what hadpreviously been determined to be the lower limit of normal odorrecognition (10⁻² mol/L), although measurements of odorant stimulusmagnitude was always requested along with each statement of odorantdetection and recognition. Thus, the actual ME determination wascalculated using the intensity and correct recognition response byaveraging intensity given from odorant concentrations 10⁻², 10⁻¹, or 100mol/L and absolute. The mean of these numbers comprised the ME response.

Because interval presentations for DT and RT were not equal, odorconcentrations were transformed to a linear scale (e.g., 10⁻⁹ mol/L=1,10⁻⁸ mol/L=2, . . . absolute=11) so that a scale of equal units and anabsolute zero was obtained. Using this scale, DT and RT for each patientwere assigned a number, and mean±SEM of responses for each patient groupwas calculated. Mean±SEM for ME for each patient group was similarlydetermined (in percentage) using the individual values previouslydetermined.

Based upon results of DT, RT, and ME, smell loss degree was classifiedas shown in Table 9. This classification indicates that patients withanosmia have the greatest severity of smell loss; those with type Ihyposmia, the next greatest; those with type II hyposmia, the nextgreatest; and those with type III hyposmia, the least severe loss.Related to severity of smell loss, acuity decreased from greatest toleast degree of smell loss such that anosmia N type I hyposmia N type IIhyposmia N type III hyposmia (Table 9).

Each measurement of saliva cAMP and cGMP was placed into 1 of the 4categories of smell loss severity. Afterward, mean±SEM for cyclicnucleotides in each group of loss severity was calculated. Differencesbetween group means were calculated using Student t tests. Biochemicaldetermination of each salivary cAMP and cGMP level was also correlatedwith each of the 4 smell loss categories by use of a Spearman rankcorrelation technique, and significance of correlation was determined.

All studies of saliva cyclic nucleotides were initially coded. Resultsof smell loss classification were obtained independent of any salivacyclic nucleotide results. Only after all patient classifications ofsmell loss were defined were saliva studies uncoded and correlated.

Results:

Levels of salivary cAMP in all patients with smell loss weresignificantly lower than those in healthy subjects (Table 10). Whencategorized by loss severity, there was a consistent decrease insalivary cAMP and cGMP with increased loss severity (Table 10).

Although only 2 patients with anosmia were studied, mean levels of bothcAMP and cGMP were lower than normal and lower than in any other smellloss type (Table 10).

Patients with the next most severe type of hyposmia (type I) hadsignificantly lower salivary levels of cAMP than did both patients withthe next least severe smell loss type (type II) and healthy subjects.When categorized by flow rate, cAMP was significantly lower than inpatients with types II and III hyposmia. When categorized with respectto protein, cAMP in patients with type II hyposmia, although notsignificantly different from that in patients with type III hyposmia,was 6% lower (Table 10) and, when characterized by flow rate levels, was7% lower (Table 10).

Levels of cGMP were 2 to 3 times lower than in healthy subjects (Table10). Although levels were not significantly different, cGMP in patientswith type I hyposmia were one half that in patients with type IIIhyposmia. In patients with type II hyposmia, levels were 46% those withtype III hyposmia. Mean salivary cGMP for patients with type IIIhyposmia (the least severe type of hyposmia), although 27% lower thanlevels of healthy subjects, were not significantly different from normallevels (Table 10).

Salivary levels of cAMP were higher than those for cGMP in all patientgroups except for the 2 patients with anosmia in whom measurements ofboth cyclic nucleotides were close to zero. However, levels of cAMP inthe patients were only 3 to 5 times higher than cGMP, whereas in healthysubjects, this difference ranged from 7 to 10 times higher.

Correlation of salivary cAMP with smell loss type was rs=−0.83 (P b0.001); correlation of salivary cGMP with smell loss type was rs=−0.79(P b.001). These demonstrate that the higher the level of salivary cGMPor cGMP, the less severe the loss of smell acuity among these patients.Saliva flow rate was significantly lower than normal only in patientswith type II hyposmia.

Salivary cyclic nucleotides were also determined in patients with smellloss classified by both degree of smell loss and sex (Table 11). Therewere no significant sex differences in either salivary cAMP or cGMPrelated to degree of smell loss. However, both men and women with typeII hyposmia were significantly older than men and women with type Ihyposmia; salivary protein was significantly lower in women with type Ihyposmia than in those with type II hyposmia (Table 11).

TABLE 9 Classification of severity of odor loss Severity of smell lossDT RT ME Anosmia 0 0 0* Hyposmia Type I − 0 0* Type II − −* ≧0 < normalType III + +* ≧0 < normal Detection threshold, RT, and ME. 0 indicatesinability to both detect and recognize correctly any odorant at anyconcentration; 0*, the patient is unable to recognize correctly anyoderant at any concentration, rendering any intensity measurementinvalid or 0; DT−, inability to detect any oderant at ≦10⁻⁵ mol/L(responses are ≧10⁻⁴ mol/L for all odorants); RT−*, inability torecognize correctly any oderant at ≦10⁻² mol/L (responses are ≧10⁻¹mol/L for all odorants); DT+, ability tp detect all oderants at ≦10⁻⁵mol/L RT+*, ability to recognize correctly all odorants at ≦10⁻² mol/L.Magnitude estimation, normal (pyridine, <61%; nitobenzene, <46%;thiophene, <63%, amyl acetate, <48%).

TABLE 10 Cyclic AMP and cGMP in parotid saliva in patients with tasteand smell loss classified by severity of loss cAMP cGMP FLOW Smellpmol/mg pmol/min pmol/mg pmol/min PROTEIN RATE AGE loss pmol/ml proteinflow rate pmol/ml protein flow rate mg/dl mL/min y Anosmia 0.22 0.063.70 0.62 0.01 0.06 0.62 3.70 56 (2) Hyposmia Type I 0.78 ± 0.09

0.26 ± 0.02

3.01 ± 0.09 0.76 ± 0.09

0.047 ± 0.010

0.18 ± 0.04 0.76 ± 0.09

3.01 ± 0.09 47 ± (54) 2 II (189) 0.87 ± 0.04

0.28 ± 0.02

3.12 ± 0.02 0.68 ± 0.07

0.047 ± 0.005

0.22 ± 0.05 0.68 ± 0.07

3.12 ± 0.02 57 ± 1 III (8) 1.01 ± 0.12

0.33 ± 0.06

3.09 ± 0.14 0.62 ± 0.15 0.091 ± 0.009 0.45 ± 0.09 0.62 ± 0.15 3.09 ±0.14 51 ± 5 Healthy 2.00 ± 0.19 0.63 ± 0.06 3.17 ± 0.18 0.92 ± 0.050.066 ± 0.009 0.23 ± 0.04 0.92 ± 0.05 3.17 ± 0.18 50 ± subjects 5 (61)Numbers in parentheses indicate number of subjects. With respecttohealthy subjects;

P < .001,

P < .005,

P < .02, and

P < .01. With respect to type III hyposmia:

P < .005.

Mean ± SEM

indicates data missing or illegible when filed

TABLE 11 Cyclic AMP and cGMP concentrations in parotid saliva of men andwomen with anosmia and hyposmia cAMP cGMP pmol/mg pmol/min pmol/mgpmol/min Protein Flow rate Age pmol/mL protein flow rate pmol/mL proteinflow rate mg/dL mL/min y Men Anosmia (2) 0.22 0.06 0.35 0.05 0.01 0.063.70 0.62 56 Hyposmia Type I (28) 0.75 ± 0.11^(a) 0.24 ± 0.04 1.03 ±0.15 0.13 ± 0.03 0.03 ± 0.012 0.18 ± 0.06 3.05 ± 0.09 0.74 ± 0.05 50 ±3^(§) Type II (109) 0.84 ± 0.07 0.27 ± 0.03 1.25 ± 0.14 0.20 ± 0.04 0.64± 0.023 0.30 ± 0.07 3.14 ± 0.09 0.67 ± 0.03 58 ± 2 Type III (2) 0.990.36 1.10 0.39 0.14 0.43 2.78 0.90 61 Women Hyposmia Type I (26) 0.79 ±0.09^(‡) 0.27 ± 0.03 1.07 ± 0.10* 0.16 ± 0.03 0.054 ± 0.010 0.22 ± 0.052.97 ± 0.11^(∥) 0.74 ± 0.05^(‡) 46 ± 3^(†) Type II (80) 0.97 ± 0.05 0.30± 0.02 1.62 ± 0.09^(¶) 0.15 ± 0.01 0.047 ± 0.004 0.25 ± 0.02 3.25 ±0.05^(#) 0.60 ± 0.02 56 ± 1 Type III (6) 1.07 ± 0.16 0.42 ± .015 1.98 ±0.07 0.21 ± 0.10 0.083 ± 0.040 0.38 ± 0.09 2.54 ± 0.10 0.54 ± 0.10 50 ±16 Numbers in parentheses indicate number of subjects. With respect totype II hyposmia: *P < .001, ^(†)P < .005, ^(‡)P < .02, ^(§)P < .05, and^(∥)P < .01. With respect to type III hyposmia: ^(¶)P < .02 and ^(#)P <.05. ^(a)Mean ± SEM.

Example 7: Intranasal Administration of Theophylline

Objective:

To determine whether intranasal theophylline methylpropyl paraben cancorrect hyposmia and hypogeusia.

Design:

We performed an open-label pilot study in patients with hyposmia andhypogeusia under the following 3 conditions: (1) before treatment, (2)after oral theophylline treatment, and (3) after intranasal theophyllinetreatment. Under each condition, we performed subjective evaluations oftaste or smell functions, quantitative measurements of taste(gustometry) and smell (olfactometry), and measurements of serumtheophylline level and body weight.

Patients:

Ten patients with hyposmia and hypogeusia clinically related to theeffects of viral illness, allergic rhinitis, traumatic brain injury,congenital hyposmia, and other chronic disease processes were selected.

Interventions:

Oral theophylline methylpropyl paraben, 200 to 800 mg/d for 2 to 12months, was administered to each patient. This treatment wasdiscontinued for 3 weeks to 4 months when intranasal theophyllinemethylpropyl paraben, 20 pg/d in each naris, was administered for 4weeks.

Main Outcome Measures:

At termination of each condition, taste or smell function was determinedsubjectively, by means of gustometry and olfactometry, with measurementof serum theophylline levels and body weight.

Results:

Oral theophylline treatment improved taste or smell acuity in 6 patientsafter 2 to 12 months of treatment. Intranasal theophylline treatmentimproved taste or smell acuity in 8 patients after 4 weeks, withimprovement greater than after oral administration. No adverse effectsaccompanied intranasal drug use. Body weight increased with eachtreatment but was greater after intranasal than after oraladministration.

Conclusions:

Intranasal theophylline treatment is safer and more effective inimproving hyposmia and hypogeusia than oral theophylline treatment.

Loss of smell (hyposmia) and taste (hypogeusia) are common symptoms thataffect many thousands of patients in the United States, as reported byseveral investigators. Effective treatment for these symptoms has beendemonstrated only recently and has not been formally established.

Before effective treatment to correct loss of smell and taste can beestablished, a biochemical basis for the cause of these symptoms isnecessary. To accomplish this, we determined that these symptoms arecommonly caused by decreased secretion of several growth factors in thesaliva and nasal mucus. The growth factors act on stem cells in tastebuds and olfactory epithelial cells to generate the elegant repertoireof cellular components in these sensory organs. Growth factorstimulation of these sensory organs is thought to maintain normal tasteor smell function. If these growth factors were diminished by any ofseveral diseases and pathological conditions, then hyposmia andhypogeusia occur. These conditions and diseases can include trace metaldeficiencies; vitamin deficiencies; liver disease; diabetes mellitus;other metabolic, otolaryngological, and neurodegenerative disorders,including multiple sclerosis, Parkinson disease, and Alzheimer disease;and other neurological disorders. Effective treatment to increasesecretion of these growth factors is therefore necessary to improvehypogeusia and hyposmia and return taste or smell function to normal asdemonstrated by several previous studies.

To understand more about these processes, a comprehensive study of manypatients with loss of smell and taste determined that levels of thesalivary and nasal mucus growth factors cyclic adenosine monophosphate(cAMP) and cyclic guanosine monophosphate (cGMP) were lower than inhealthy subjects and were responsible for the onset of hyposmia andhypogeusia in many of these patients. Indeed, as hyposmia increased inseverity, levels of these salivary and nasal mucus growth factorsdecreased in a consistent manner.

To increase salivary and nasal mucus cAMP and cGMP levels and therebycorrect hypogeusia and hyposmia, we hypothesized that treatment with aphosphodiesterase inhibitor would be useful. To test this hypothesis, aprevious study from our institution administered oral theophylline to312 patients with hyposmia and hypogeusia in an open-label controlledclinical trial. Results of this study demonstrated that oraltheophylline treatment successfully corrected hyposmia in more than 50%of these patients. Subsequent investigators have used other oralphosphodiesterase inhibitors to correct hyposmia. An open-label studyalso demonstrated that, as nasal mucus cAMP and cGMP levels increased,hyposmia was corrected, whereas in patients in whom these moieties didnot increase, hyposmia was not corrected. These results suggested thatsome patients can be resistant to treatment with oral theophylline.

However, successful treatment with oral theophylline that increasednasal mucus levels of cAMP and cGMP required increased theophyllinedoses, sometimes prolonged treatment duration, and endurance of adverseeffects, including restlessness, gastrointestinal tract discomfort,sleep difficulties, tachycardia, and other unwanted symptoms.Theophylline treatment also required regular determinations of bloodtheophylline levels to ensure adequate drug absorption and lack of toxiceffects. These efforts limited use of this orally administered drug.

Because of these adverse effects, we wished to learn more about thepharmacology of theophylline administration. After treatment with oraltheophylline, the drug was found in blood, nasal mucus, and saliva in adose dependent manner. These results were consistent with improvement insmell function as demonstrated in patients with hyposmia in the priorclinical trial. Results of these studies and efforts to improvetherapeutic efficacy and reduce adverse effects of oral theophyllineadministration resulted in intranasal administration of the drug. Inthis manner, the drug could affect olfactory receptors more directlywithout causing the systemic adverse effects associated with oraltherapy.

To accomplish this, with assistance of an established medical devicecompany, an intranasal delivery device was developed. With assistance ofan established pharmaceutical company, the drug was packaged forsterile, intranasal delivery. Using this device, an open-label, singlesource, controlled pilot study in 10 patients with hyposmia andhypogeusia and with levels of parotid saliva and nasal mucus cAMP andcGMP below the reference range was performed to determine safety and tocompare smell and taste responses after intranasal theophyllinetreatment, with patient responses before any treatment and after oraltheophylline treatment.

Methods

Patients

We selected 10 patients with hyposmia and hypogeusia from the 312patients who participated in the prior open-label controlled clinicaltrial for this pilot study. Each patient had undergone previousevaluation before any drug treatment, followed by treatment with oraltheophylline. These patients had hyposmia and hypogeusia and exhibitedlevels of cAMP and cGMP lower than their respective reference ranges inthe saliva and nasal mucus before theophylline treatment. These 10patients were selected from the group undergoing previous evaluation andtreatment for the intranasal trial because (1) their response to oraltheophylline was subjectively submaximal; (2) they developed adverseeffects after attempts to increase the drug dose to obtain a moremaximal clinical response, thus limiting the administered drug dose; and(3) they resided in an area in close proximity to The Clinic, which madetheir frequent return visits to The Clinic more practical for anyadditional clinical trial.

These 10 patients included 7 men, aged 37 to 77 (mean [SEM] age, 64 [6])years, and 3 women, aged 47 to 77 (62 [1 1]) years. Patients had 1 ofthe following 5 different clinical causes of sensory dysfunction:allergic rhinitis (n=3), post influenza-like hyposmia and hypogeusia(n=3), head injury (n=2), congenital hyposmia49 (n=1), and otherdisorders (n=1). Patients served as their own control throughout eachcondition of this study. The conditions included no treatment (beforeentry into the oral theophylline study), oral theophylline treatment,and intranasal theophylline treatment.

Procedures

Subjective changes in smell and taste function under each studycondition were measured by questionnaire before measurements of smell ortaste function. Responses were graded on a scale from 0 to 100, with 0reflecting no subjective response in overall sensory function; 100,return to normal sensory function; and values between 0 and 100intermediate responses. Overall sensory function was defined as theability to smell all odors and identify all tastants, although responseintensity varied.

Smell and taste functions under each study condition were measured bystandardized psychophysical sensory testing techniques. Measurementsincluded determination of detection thresholds (DTs), recognitionthresholds (RTs), magnitude estimation (ME), and hedonic response (HR)for 4 odors (i.e., pyridine [dead fish], nitrobenzene [bitter almond],thiophene [petroleum], and amyl acetate [banana oil]) (olfactometry) andfor 4 tastants (i.e., sodium chloride [salt], sucrose [sweet],hydrochloride [sour], and urea [bitter]) (gustometry). These techniqueshave been previously described with olfactometry confirmed in a priorcontrolled double-blind clinical trial. Each measurement was performedindependent of any prior knowledge of response.

Serum theophylline levels were measured by fluorescence polarization ateach treatment condition. Body weight was measured with a calibratedclinical scale during each study condition and reported at the finalmeasurement in each study condition.

Study Protocol

The patients each underwent initial clinical evaluation at The Clinic toestablish the cause, degree, and character of hyposmia and hypogeusiaexhibited. Measurements in blood, urine, erythrocytes, saliva, and nasalmucus determined before their entry into the open trial of oraltheophylline established the biochemical cause of their hyposmia andhypogeusia to be related to their levels of saliva and nasal mucus cAMPand cGMP being lower than the reference range. These 10 patients werethen selected for this study on the basis of the laboratory and clinicalcriteria noted previously.

The 10 patients in this intranasal pilot study entered into the previousoral theophylline study according to a protocol approved by theinstitutional review board of the Georgetown University Medical Center.In this prior trial, oral theophylline was administered daily in 2divided doses (at breakfast and lunch) of 200, 400, 600, or 800 mg for 2to 12 months of treatment. Treatment was divided into 2- to 4-monthperiods, at which time patients returned to The Clinic for measurementsof subjective sensory responses, olfactometry, gustometry, serumtheophylline level, and body weight. If oral theophylline treatmentfailed to correct hyposmia at a given dose, the theophylline dose wasincreased by 200 mg, and the patient underwent reevaluation at 2- to4-month intervals to a dose of 800 mg. As noted previously, studypatients did not obtain a maximal clinical response to oraltheophylline' or, while taking oral theophylline at a given dose,demonstrated some clinical improvement but experienced significantadverse effects that limited increasing the oral dose as necessary toachieve maximum clinical benefit. In the 10 patients selected for theintranasal pilot study, oral theophylline treatment was discontinued 3weeks to 4 months before initiation of the intranasal drug trial. Atthat time, the mean (SEM) serum theophylline level was unmeasurable inany patient (0 [0] mg/L).

A pilot study of intranasal theophylline treatment was then initiatedamong these 10 patients. This trial was an investigator initiated phase1, open-label, single-source, controlled pilot study. Intranasal drugtherapy reflected a compassionate trial of a potentially more usefultherapeutic method to improve hyposmia (and hypogeusia) than oraltheophylline. Before the intranasal trial, risks and benefits wereexplained and the patients signed an informed consent.

The intranasal administration device was a calibrated 1 mL syringefitted with a nozzle that fit comfortably into the anterior naris (WolfeTory Medical, Inc.) and loaded under sterile conditions with 20 pg oftheophylline methylpropyl paraben in a 0.4-mL saline solution(Foundation Care). Patients were instructed to direct the spraysuperiorly into the nasal cavity but not posteriorly into thenasopharynx. This technique was practiced before study initiation withsterile saline. Each patient used the technique easily and asdemonstrated before drug administration.

Each patient delivered the theophylline dose in each naris once dailythroughout the study. Patients underwent evaluation 1, 2, and 4 weeksduring drug use with the same measurements used for the oral study.

Values for the oral trial were taken from the last measurements madebefore discontinuation of oral drug treatment and before initiation ofthe intranasal trial. This period varied from 2 to 12 months after oraltreatment initiation and reflected the maximal improvement in sensoryfunction each patient experienced. Values for the intranasal pilot studywere taken from measurements obtained after completion of 4 weeks ofintranasal treatment.

The mean and standard error of the mean for all values obtained at eachstudy condition were compared. Differences were considered significantif P<0.05 by the unpaired t test. Paired comparison tests were also usedwith differences considered significant if P<0.05 by the t test.

Results

With oral theophylline administration, hypogeusia improved after 2 to 12months of treatment, but hypogeusia improved further within 1 to 4 weeksof intranasal treatment. Before treatment, DTs for sucrose,hydrochloride, and urea (less sensitive) and RTs for all tastants wereelevated (less sensitive) above the reference levels. Magnitudeestimations for all tastants were lower (less sensitive) than thereference level. Hedonic responses for sodium chloride, hydrochloride,and urea were lower (less unpleasant) than the reference levels. Afteroral theophylline treatment, DTs for sucrose and hydrochloride and RTsfor sodium chloride, hydrochloride, and urea decreased (more sensitive).Magnitude estimations for all tastants increased (more sensitive) and HRfor hydrochloride and urea increased (more unpleasant) as previouslyreported. After intranasal theophylline treatment, DTs and RTs for alltastants were lower (more sensitive) than before treatment or after oraltheophylline treatment. Magnitude estimations for all tastants afterintranasal theophylline treatment were higher (more intense) than beforeany treatment or after oral theophylline treatment. Hedonic responsesfor sodium chloride, hydrochloride, and urea were more negative (moreunpleasant), whereas HRs for sucrose were more positive (more pleasant)than before any treatment or after oral theophylline treatment.

After oral theophylline treatment, hyposmia improved with 2 to 12 monthsof treatment but improved more with intranasal theophylline after 1 to 4weeks of treatment. Before treatment, compared with reference levels,DTs and RTs for all odorants were elevated (less sensitive); MEs for allodorants were decreased (less sensitive); HRs for pyridine and thiophenewere decreased (less unpleasant); and HRs for nitrobenzene and amylacetate were decreased (less pleasant). After oral theophyllinetreatment, DTs and RTs for all odorants were decreased (more sensitive),MEs for all odorants were increased (more sensitive), and HRs for allodorants increased (for pyridine and thiophene, more unpleasant; fornitrobenzene and amyl acetate, more pleasant) as previously reported.After intranasal theophylline treatment, DTs and RTs for each odor werelower (more sensitive) than before treatment or after oral theophyllinetreatment. Magnitude estimations for each odor were higher (moreintense) than before treatment or after oral theophylline treatment.Hedonic responses to thiophene were more negative (more unpleasant) andto nitrobenzene were more positive (more pleasant) than before treatmentor after oral theophylline treatment.

Smell and taste acuity were reported to be subjectively improved withoral theophylline treatment, but greater improvement was reported after4 weeks of intranasal theophylline treatment. After oral theophyllinetreatment, 6 patients reported overall increased taste or smellfunction, whereas 4 reported no improvement. After intranasaltheophylline treatment, 8 of the 10 patients reported overallimprovement in taste or smell functions, whereas 2 reported noimprovement. This response frequency is higher than that previouslyreported among patients with hyposmia and treated with oraltheophylline, in which slightly more than 50% reported improvement.

Taste or smell acuity were measured as subjectively improved after oraltheophylline treatment, but this improvement was measured as increasedafter 4 weeks of intranasal theophylline treatment. After intranasaltheophylline treatment, a 2-fold improvement was measured for taste orsmell functions compared with oral treatment. Paired t test resultsshowed that responses after intranasal theophylline were significantlygreater than after oral theophylline treatment (taste, P<0.05; smell,P<0.025).

Body weight increased from pretreatment levels after oral theophyllinetreatment, but weight increased more after intranasal theophyllinetreatment. After oral theophylline treatment, mean (SEM) weightincreased by 1.5 (0.4) kg from pretreatment values, whereas afterintranasal theophylline treatment, weight increased by 2.5 (0.5) kg frompretreatment values. Patients related this change to increased foodflavor obtained by improved smell function after intranasal theophyllinetreatment, which increased appetite and food enjoyment, resulting insubsequent weight gain. These changes were measured in each patientgroup despite no sensory improvement in 4 patients after oraltheophylline treatment and none in 2 after intranasal theophyllinetreatment.

During oral theophylline treatment, the mean (SEM) serum theophyllinelevel at the time of maximum improvement for these 10 patients was 6.4(2.0) mg/L (to convert to micromoles per liter, multiply by 5.55).During intranasal theophylline treatment, the mean serum theophyllinelevel was 0.0 (0.0). Discontinuation of intranasal theophyllinetreatment resulted in loss of smell and taste function within 1 week in2 patients and after 6 weeks in 2. Four patients reported somepersistence of improvement after 10 weeks.

Comment

Results of this open-label, single-source, controlled pilot trialdemonstrates that oral theophylline effectively improved hyposmia, aspreviously reported. The earliest this improvement was measured wasafter 2 months of treatment, but maximal improvement varied from 4 to 12months. These results also demonstrate that oral theophylline waseffective in improving hypogeusia in the same time frame as improvementin smell acuity.

In addition, intranasal theophylline was shown to be safe and moreeffective than oral theophylline in correcting hyposmia and hypogeusia.This improvement was measured as early as 1 week after startingtreatment, but maximal improvement varied from 1 to 4 weeks.

Mechanisms by which intranasal theophylline was more effective than oraltheophylline are not clearly defined. Intranasal drug delivery avoidsthe first-pass hepatic effect of an oral drug, bypassing initialcytochrome P450 metabolism and decreasing metabolism of the orallyadministered drug, thereby allowing for lower intranasally administereddrug doses to be clinically efficacious. This lowering of the drug dosefrom a range of 200 to 800 mg orally to 40 pg intranasally wassufficient and specific enough to also avoid production of systemicadverse effects. This delivery mechanism may also avoid development ofdrug resistance that has occurred with oral theophylline. In addition,because more drug presumably contacts the olfactory epithelium withintranasal than with oral theophylline, direct nasal administration mayactivate more olfactory receptors than does oral administration.

However, additional actions of intranasal theophylline might enhance itstherapeutic efficacy. Theophylline has been shown to inhibit symptoms ofallergic rhinitis, which affected 3 patients in the intranasal trial.Many of the diseases and conditions that caused hyposmia and hypogeusiahave an associated inflammatory component that can be suppressed by theanti-inflammatory effects of a phosphodiesterase inhibitor. In addition,drugs introduced intranasally can be delivered into the brain (1)directly by absorption through the cribriform plate along the olfactorybulb, (2) indirectly by absorption through blood-brain barrierreceptors, or (3) through combinations of both methods. Although studiesof theophylline absorption from nasal mucus into the brain have not beenperformed, studies of insulin, nerve growth factor, severalneurotransmitters, and other moieties indicate uptake of theseintranasally introduced moieties into the brain.

Whatever its mechanism of action, intranasal theophylline in this pilotstudy corrected hyposmia and hypogeusia relatively rapidly in 8 of 10patients with several clinical diagnoses. The 2 patients who did notexperience improvement were men, one with allergic rhinitis and theother with the effects of viral illness.

These results are consistent with prior studies in which severalintranasal drugs were more effective than oral drugs. Inhaledadrenocorticosteroids were more effective with fewer adverse effects forasthma treatment than oral adrenocorticosteroids, and inhaledadrenocorticosteroids were more efficacious in asthma treatment thanoral prednisolone acetate. Intranasal zolmitriptan achieved fastercontrol of migraine headaches with fewer effects than the orallyadministered drug. Nasal administration of chicken type II collagensuppressed adjuvant arthritis in rats more effectively than oraladministration.

However, intranasally administered drugs have also been reported to beonly as effective as these same drugs given orally. Intranasal estradiolvalerate was as effective as oral administration in alleviatingpostmenopausal symptoms but produced less frequent mastalgia and uterinebleeding. Intranasal desmopressin acetate was as effective for nocturnalenuresis as the oral drug but at a dose one-tenth that of the oral drug.Intranasal desmopressin is the preferred route for management of centraldiabetes insipidus.

Example 8. Treatment with Antibody Inhibitors of IL-6

In this example, a subject with hypogeusia or ageusia is treated byadministration of an effective amount of an inhibitory antibody againstIL-6 or a receptor of IL-6. The inhibitory antibody can be tociluzumab,sarilumab, elsilimomab, siltuximab, sirukumab, BMS-945429, CDP6038,VX30, ARGX-109, or FM101. The administration is by intranasaladministration. Treatment efficacy is evaluated by administering thestandardized psychophysical sensory testing techniques before and afteradministration of the antibody. The administration is repeated asnecessary according to the efficacy testing data. Recipient's ability totaste or smell improves according to the standardized psychophysicalsensory testing.

Example 9. SHH in Hyposmia

Objective:

To determine the presence of SHH in human nasal mucus in normal subjectsand in patients with smell loss (hyposmia).

Methods:

SHH was measured in 14 normal subjects and in 44 untreated patients withsmell loss (hyposmia) of several causes and in 30 of these patientsafter treatment with oral theophylline using sensitivespectrophotometric ELISA assay.

Results:

SHH was present in nasal mucus in both normal subjects and in patientswith hyposmia. However, SHH levels in hyposmic patients weresignificantly lower than in normal subjects. After treatment with oraltheophylline, SHH levels in nasal mucus increased significantly to over300 times higher than in the untreated state associated. 60% of patientsexhibited improved smell function.

Conclusion:

SHH may act as a cell signaling moiety to stimulate stem cells inolfactory epithelium; its diminution in hyposmic patients compared tonormals suggests that SHH serves as a biochemical marker for smell lossand acts as a growth factor to maintain normal olfactory function.

Introduction

Members of the hedgehog signaling pathway belong to a family ofextracellular signaling molecules involved in the regulation of multiplephysiological processes including invertebrate and vertebrate embryodevelopment. Vertebrate organisms express multiple forms of hedgehog;there are three known hedgehogs in mammals—Sonic hedgehog (SHH), Indianhedgehog (IHH) and Desert hedgehog (DHH). SHH plays an important role inseveral developmental processes involving induction of dopaminergicneurons and cholinergic neurons.

SHH is synthesized as a 45-kD precursor protein that is cleavedautocatalytically to yield a 20-kD N-terminal fragment with acholesterol molecule covalently attached to the C-terminal glycine and a25-kD C-terminal fragment. Its crystal structure has been determined andit is structurally homologous to several zinc-dependent hydrolases. Thecrystal structure of SHH reveals one zinc atom coordinated by twohistidines and a glutamate residue. Removal of zinc from SHH inhibitsits activity. Increase in activity of cAMP-dependent protein kinase Aantagonizes SHH signaling.

Methods

Subjects:

Forty-four patients, aged 10-88 y, 56±3 y (Mean±SEM) took part in thisstudy. Patients were 24 men, aged 12-88 y, 54±4 y, and 20 women, aged10-84 y, 51±5 y. All patients exhibited smell loss as measured bysubjective statement and olfactometry, as previously described.Olfactometry can include determination of detection (DT) and recognition(RT) thresholds and magnitude estimation (ME) for four odors (pyridine,nitrobenzene, thiophene and amyl acetate). Abnormalities of smellfunction consisted of increased DT or RT above normal (decreasedsensitivity) and/or decreased ME (decreased sensitivity) for one or moreof the odors presented. Patients exhibited six etiologies related totheir smell loss: post-influenza-like hyposmia [(PIHH) 10 patients],allergic rhinitis [15 patients], congenital loss of smell [ninepatients], head injury [eight patients], post general anesthesia [onepatient] and dysgeusia and oropyrosis [one patient].

Thirty of the hyposmic patients were treated with oral theophylline witha dose range of 200-800 mg taken over a period of 2-10 months. Thesepatients were 17 men, aged 12-78 y, 62±5 y, six with PIHH, nine withallergic rhinitis, one with congenital smell loss and one postanesthesia, and 13 women, aged 12-67 y, 42±6 y, with four with PIHH, onewith allergic rhinitis and eight with congenital smell loss. Improvementin smell function consisted of decreased DT or RT (increasedsensitivity) and/or increased ME (increased sensitivity) for one or moreof the presumed odors.

Normal Subjects:

Fourteen subjects who presented to The Taste or smell Clinic inWashington, D.C. for evaluation of symptoms unrelated to smell loss andother volunteers were a part of this study. Normal subjects wereselected in a consecutive manner and included all subjects who exhibitedno sensory abnormalities.

Study protocols were previously approved by the Georgetown UniversityMedical Center Institutional Review Board. Each participants of thestudy voluntarily agreed and signed an informal consent participationform.

Procedures:

Patients and subjects were instructed to deposit all the nasal mucusthey produced spontaneously over a period of 1-4 days into a 50 mlplastic tube. All samples were refrigerated overnight and collection waslonger than 24 hrs.

Each sample was transferred to a 12 ml plastic tube and centrifuged in arefrigerated RC2B Spinco centrifuge at 18,400 rpm for 45-55 min. Thesupernatant was transferred to PCR tubes and stored at −20° C. untilanalyzed.

Each sample was analyzed by using a specific spectrophotometric ELISAtechnique obtained from Abcam Inc. (Cambridge, Mass.). Analysis ofduplicate samples agreed within 5%. All analyses were made independentof the knowledge of the status of any subject. Only after all sampleswere analyzed and results tabulated were samples codified inrelationship to clinical diagnosis. Results were analyzed such thatMean±SEM levels in each category were obtained and results comparedusing Student t tests with p<0.05 considered significant.

Results

SHH was measured in the nasal mucus of all participants (Table 12).Levels of SHH in patients were less than 2% of the levels of SHH foundin normal subjects (Table 12).

Mean SHH levels in women were 1.5 times higher than in men (Table 13).

Mean SHH levels in patients having a wide range of etiologies for thecause of their smell loss, varied widely (Table 14). Patients withgeneral anesthesia exhibited the lowest levels of any patient groupfollowed in rank order by patients with allergic rhinitis, congenitalsmell loss, the patient with dysgeusia and oropyrosis, head injury andPIHH. Mean SHH levels of each patient group were significantly lowerthan in normal subjects.

Treatment with oral theophylline significantly increased SHH levels byover 330 times among patients (Table 14). Theophylline levels increasedsignificantly above normal levels in both men and women with an increaseof 320 times in men but only 17 times in women (Table 14). However,prior to theophylline treatment SHH levels in women were significantlyhigher than in men (p<0.001).

Categorized by etiology each patient group studied exhibited asignificant increase in nasal mucus SHH (Table 15). Patients withallergic rhinitis increased the greatest amount (by over 719 times theuntreated state), next the patient post anesthesia (by 48 times), bypatients with PIHH (by 46 times) and least by patients with congenitalsmell loss (by over 21 times).

Oral theophylline treatment in PIHH patients increased SHH to levelssignificantly above levels in all patients before theophylline treatment(Table 15). However, levels in treated patients with allergic rhinitisand congenital smell loss and following general anesthesia did notexhibit as much change in SHH levels and were below the mean of alltreated patients.

Improvement in smell function after oral theophylline treatment occurredin 19 of 31 patients or an overall improvement in 61%.

Discussion

This study indicates that SHH is present in the nasal mucus in bothnormal subjects and in untreated patients with hyposmia. However, levelsin untreated hyposmic patients were significantly lower than in normalsubjects similar to results previously demonstrated for levels of nasalmucus cAMP and cGMP which were also significantly lower than in normalsubjects. Treatment with oral theophylline significantly increased SHHlevels in nasal mucus of patients with hyposmia over those measured inthe untreated state consistent with results previously demonstrated forlevels of nasal mucus cAMP and cGMP. Prior treatment among priorhyposmic patients with oral theophylline resulted in smell improvementin slightly over 50% of patients whereas in this study 60% of patientsexhibited improvement in smell function. Among prior theophyllinetreated hyposmic patients some exhibited resistance to oral theophyllinetreatment, a result which also may have occurred among patients in thisstudy.

TABLE 12 SONIC HEDGEHOG IN NASAL MUCUS IN NORMAL SUBJECTS AND INPATIENTS WITH HYPOSMIA SUBJECTS SONIC HEDGEHOG* PATIENTS (44) 149 ±2^(+,a) NORMALS (14) 7538 ± 1105 ( ) Subject number *in pg/ml ⁺Mean ±SEM With respect to normals ^(a)p < 0.001

TABLE 13 SONIC HEDGEHOG IN NASAL MUCUS IN PATIENTS WITH HYPOSMIACLASSIFIED BY ETIOLOGY OF SMELL LOSS SUBJECTS SONIC HEDGEHOG* ALLPATIENTS (44) 149 ± 2^(+,a) PIHH (10) 1527 ± 159^(a) ALLERGIC RHINITIS(15) 34 ± 2^(a) CONGENITAL (9) 180 ± 12^(a) HEAD INJURY (8) 1396 ±252^(a) DYSGEUSIA WITH OROPYROSIS (1) 226 POST GENERAL ANESTHESIA (1)1.3 NORMALS (14)  7538 ± 1105 ( ) Subject number *in pg/ml ⁺Mean ± SEMWith respect to normals ^(a)p < 0.001

TABLE 14 SONIC HEDGEHOG IN PATIENTS WITH HYPOSMIA UNTREATED AND AFTERTREATMENT WITH ORAL THEOPHYLLINE CONDITION Treatment With SUBJECTSUntreated Oral Theophylline‡ NORMALS 7538 ± 1105 (14) MEN 150 ± 6^(a1)(24) 47952 ± 3085^(a,a1) (18) WOMEN 229 ± 8^(a1) (20) 38590 ±3030^(a,a1) (13) ALL PATIENTS 149 ± 2^(+,a1) (44) 49191 ± 1710^(a,a1)(31) ( ) Subject number ⁺Mean ± SEM of sonic hedgehog concentration (inpg/ml) ‡Oral theophylline (400-800 mg daily for 2-10 months) Withrespect to untreated patients ^(a)p < 0.001 With respect to nomials^(a1)p < 0.001

TABLE 15 SONIC HEDGEHOG IN NASAL MUCUS IN PATIENTS CLASSIFIED BYETIOLOGY UNTREATED AND TREATED WITH ORAL THEOPHYLLINE SMELL CONDITION*IMPROVEMENT Treatment With Patient PATIENTS Untreated Oral TheophyllineNumber (%) ALL PATIENTS 149 ± 2 (44) 49191 ± 1710^(a) (31) 19 (61)  PIHH1537 ± 159^(+,a1) (10) 70735 ± 5751^(a,a1) (10) 8 (80) ALLERGIC RHINITIS34 ± 2^(a2) (15) 24460 ± 2610^(a,a1) (11) 5 (45) CONGENITAL 180 ±12^(a2) (9) 3825 ± 474^(a,a1) (9) 5 (56) HEAD INJURY 1396 ± 252^(a1) (8)DYSGEUSIA WITH 226 (1) OROPYROSIS POST GENERAL 1.3 (1) 57 (1)  1 (100)ANESTHESIA NORMALS 7538 ± 1105 (14) ( ) Patient number *Sonic hedgehogconcentration (in pg/ml) ⁺Mean ± SEM With respect to untreated patients^(a1)p < 0.001 With respect to untreated patients ^(a2)p < 0.001

Example 10: Improved Smell Function Associated with Increased SonicHedgehog in Nasal Mucus in Patients with Hyposmia after Treatment withOral Theophylline

Purpose:

To demonstrate improvement in smell function in hyposmic patients aftertreatment with oral theophylline in relationship to increased nasalmucus levels of sonic hedgehog (SHH).

Methods:

Forty-four hyposmic patients were evaluated by olfactometry and bymeasurement of SHH in nasal mucus. Thirty-one of these patients weretreated with oral theophylline at doses of 200-800 mg for periods of2-10 months, at which time their smell function was evaluated bysubjective measurements, by olfactometry and by SHH measurements innasal mucus by use of a sensitive spectrophotometric ELISA assay.

Results:

There was a consistent and significant improvement in subjectiveresponses in smell function, in olfactometry and in nasal mucus SHH intheophylline treated patients.

Conclusions:

Improvement in smell function and in SHH levels in nasal mucus werepositively correlated in a dose-response relationship after treatmentwith oral theophylline. These results indicate the role of theophyllinein the successful treatment of smell function in hyposmic patients ofvarious etiologies and of SHH as a biochemical marker for smellfunction. Without being bound by theory, it is possible thattheophylline acts as a stimulator of olfactory epithelial stem cellgrowth and development.

The purpose of the present study is to evaluate changes both in smellfunction and SHH levels in nasal mucus before and after oraltheophylline treatment in patients with hyposmia of several etiologies.

Methods

Subjects

Normal Subjects.

Fourteen volunteers with normal smell and taste function were studied.These subjects were either patients who were presented to The Taste andSmell Clinic in Washington, D.C. for evaluation of symptoms unrelated tosmell loss or who were employees of The Taste and Smell Clinic whovolunteered for the study. Subjects were selected in a consecutivemanner and included all subjects who volunteered for the study.

Patients.

Forty-four patients, aged 10-88 y, 56±3 y (Mean±SEM) who presented toThe Taste and Smell Clinic in Washington, D.C. for evaluation andtreatment of smell loss were also subjects of the study. Patients wereselected consecutively from patients evaluated at The Clinic from2012-2013. Patients were 24 men, aged 12-88 y, 54±4 y and 20 women, aged10-84 y, 51±5 y. All patients exhibited smell loss as measured bysubjective statements and by olfactometry. Olfactometry was measured bydetermination of detection (DT) and recognition (RT) thresholds,magnitude estimation (ME) and hedonic evaluation (H) for four odors(pyridine, nitrobenzene, thiophene and amyl acetate). Abnormalities ofsmell function consisted of increased DT and/or RT above normal(decreased sensitivity) and/or decreased ME (decreased sensitivity) forone or more of the odors presented or decreased unpleasantness for odorsof pyridine and thiophene or increased unpleasantness for odors ofnitrobenzene or amyl acetate.

Patients exhibited six etiologies related to their smell loss:post-influenza-like hyposmia [(PIHH) 10 patients], allergic rhinitis [15patients], congenital loss of smell [nine patients], head injury [eightpatients], post general anesthesia [one patient] and dysgeusia andoropyrosis [one patient].

Thirty-one of the hyposmic patients were treated with oral theophyllinewith a dose range of 200-800 mg taken over a period of 2-10 months.These patients were 18 men, aged 12-78 y, 62±5 y, with six with PIHH, 10with allergic rhinitis, one with congenital smell loss and one postanesthesia and 13 women, aged 12-67 y, 42±6 y, with four with PIHH, onewith allergic rhinitis and eight with congenital smell loss. Improvementin smell function consisted of improvement in both subjective responsesto oral theophylline and in olfactometry. Subjective improvement insmell function consisted of measurements of improvement in perceptionfor all external odors based upon a scale of 1-100 with 100 indicatingcomplete recovery of normal smell function with responses from 1-100scaled appropriately. Improvement in flavor perception was measured byresponses of a 1-100 scale with 100 indicating that all flavors of foodwere considered normal and responses <100 scaled consistently less.Subjective improvement in taste function was also measured with changesin taste for salt, sweet, sour and bitter tastants measured on the same1-100 scale with 100 indicating return to normal for each of the fourtastants considered and responses <100 scaled consistently less.Improvement by olfactometry was indicated by decreased DT or RT(increased sensitivity), increased ME (increased sensitivity) andchanges in H consistent with decreased distortions.

Olfactometry improvement reflects specific changes in sensory function.Decreased DTs after theophylline treatment reflect increased olfactorydetection function with increased receptor sensitivity. Decreased RTsafter this treatment reflect improvement with increased sensitivity inolfactory receptor-brain relationships. Increased MEs reflect increasedolfactory receptor number. Changes in H reflect changes in brainfunction related to decreased perception of olfactory distortions.

Study protocol was consistent with studies previously approved by theInstitutional Review Board of the Georgetown University Medical Center.Each patient and subject agreed to participate in the study and signedan informed consent participation form.

Methods

Patients and volunteers collected all nasal mucus they spontaneouslyproduced over a period of 1-4 days into a 50 ml plastic tube. Allsamples were refrigerated overnight for collections longer than 24 h.

Each sample was transferred to a 12 ml plastic tube and centrifuged in arefrigerated RCSC Plus Sorvall centrifuge at 18,000 rpm for 45-55 min.Supernatant was transferred to PCR tubes and stored at −20° C. untilanalyzed.

Each sample was analyzed by use of a sensitive spectrophotometric ELISAtechnique obtained from Abcam Inc. (Cambridge, Mass.). Analysis ofduplicate samples agreed within 5%. All analyses were made independentof the knowledge of the status of any subject. Only after all sampleswere analyzed were results tabulated and samples classified inrelationship to subject status.

Results were analyzed such that mean±SEM levels in each category wereobtained and results compared using Student t tests with p<0.05considered significant. Comparison of results of SHH levels with respectto oral theophylline doses were also analyzed by use of Pearson productcorrelation with statistical improvement measured by p<0.05.

Results

Smell function in hyposmic patients before and after oral theophyllineassociated with levels of SHH in nasal mucus is shown in Table 16. Smellfunction in the untreated hyposmic patients were significantly impairedwith respect to normal subjects with respect to DTs and RTs forpyridine, thiophene and amyl acetate and with respect to DT fornitrobenzene. After treatment with oral theophylline there wassignificant improvement in smell function. There were significantdecreases with respect to the untreated state in DTs for pyridine,nitrobenzene, thiophene and amyl acetate and RTs for nitrobenzene. MEsfor all odors increased except for thiophene and Hs increased inunpleasantness for pyridine and increased in pleasantness for amylacetate. These changes were associated with significant increases in SHHin the treated patients.

Subjective changes in smell function following treatment with oraltheophylline are shown in Table 17. Of the 31 patients treated 19 (61%)improved with a range of 2-100% with a mean improvement of 34±6%. Ofthese improved patients 11 were men with a mean improvement of 27±9% andeight were women with a mean improvement of 43±17%.

Flavor perception improved in 19 patients (61%) consistent with theirimprovement in smell function. Taste function improved in 20 patients(64%).

Changes in smell function and in nasal mucus SHH levels and in nasalmucus SHH levels before and after treatment with oral theophyllinebefore treatment and after treatment with each of the four doses of oraltheophylline are shown in Table 18. With each increased dose of oraltheophylline there was both a consistent and significant increase in SHH[(r=0.91) (p<0.001)] and a decrease in DT and RT (increased sensitivity)for each odor presented except for the RT of thiophene at 400 mg. Therewas an increase in ME for all doses of 600 mg and 800 mg of oraltheophylline and similar increases in H for the unpleasantness ofpyridine and thiophene and increases in pleasantness of nitrobenzene andamyl acetate.

Changes in smell function in relationship to changes in SHH in nasalmucus in untreated men and women are shown in Table 19. Before treatmentthere were no significant differences in any aspect of smell functionbetween men and women although DT and RT were lower (more sensitive) inwomen for nitrobenzene, thiophene and amyl acetate. ME values werehigher (more sensitive) in untreated women than in untreated men forthese same odors. After treatment DTs and RTs for pyridine andnitrobenzene were significantly lower (more sensitive) in men than inwomen and DTs and RTs were lower (more sensitive) for thiophene and amylacetate in men than in women but not significantly so. However, aftertreatment measurements of unpleasantness for pyridine and thiophene (Hvalues) were judged more unpleasant in women than in men andmeasurements of pleasantness (H values) were judged more pleasant inwomen than in men although changes were not significant. In theuntreated state SHH levels in nasal mucus in women were significantlyhigher than men whereas after treatment SHH in men were significantlyhigher than in women.

Discussion

These results indicate that SHH levels in nasal mucus serves not only asan index of loss of smell function in untreated hyposmic patients butalso as an index of improvement after treatment with oral theophylline.These results confirm the usefulness and importance of collecting andmeasuring changes in nasal mucus as an important biological fluid in theevaluation of patients with hyposmia.

These results also suggests that SHH acts as a growth factor to promotereceptor function in olfactory epithelial maturation and perpetuationand in taste bud growth and development.

Results of these studies indicate that oral theophylline increases nasalmucus levels of SHH in hyposmic patients and that this treatmentimproves smell function.

It is useful to note the dose response improvement in smell function tooral theophylline treatment and in increases in nasal mucus SHH. Theseresults are consistent with the relationship between smell improvementand increased SHH concentration in nasal mucus.

There were significant differences discovered between normal subjectsand hyposmic patients both with respect to smell function and SHHchanges in nasal mucus.

TABLE 16 CHANGES IN SMELL FUNCTION AND IN SONIC HEDGEHOG (Shh) LEVELS INNASAL MUCUS BEFORE AND AFTER TREATMENT WITH ORAL THEOPHYLLINE PYRIDINENITROBENZENE CONDITION DT RT ME H DT RT ME H PATIENTS UNTREATED (44) 7.8± 0.4

8.7 ± 0.4^(a1) 34 ± 4 −30 ± 4 8.0 ± 0.6^(a1) 9.0 ± 0.3 17 ± 4 6 ± 3TREATED (31) 5.7 ± 0.7

6.7 ± 0.8^(c ) 40 ± 6 −32 ± 6 4.7 ± 0.9

5.6 ± 0.9

19 ± 4 2 ± 3 NORMALS (14) 3.0 ± 0.4 4.1 ± 0.5   52 ± 5 −51 ± 5 1.4 ± 0.32.4 ± 1.0 52 ± 5 3 ± 1 *Mean ± SEM ( ) Patient number DT, detectionthreshold (in BU) RT, recognition threshold (in BU) ME, magnitudeestimation (in %) H, hedonic value (in %) Shh (in pg/ml) Treated withrespect to untreated ^(a)p < 0.001 ^(b)p < 0.005 ^(c)p < 0.02 ^(d)p <0.05 Untreated with respect to normals ^(a1)p < 0.001 Treated withrespect to normals ^(a2) ^(b2) ^(c2) ^(d2) THEOPHENE AMYL ACETATE SONICCONDITION DT RT ME H DT RT ME H HEDGEHOG PATIENTS UNTREATED (44)

.1 ± 0.6

9.5 ± 0.5

20 ± 4

−13 ± 4

8.2 ± 0.6

9.2 ± 0.5

16 ± 3

0.4 ± 3 149 ± 2

TREATED (31) 5.1 ± 0.7

5.5 ± 0.8

18 ± 4

−9 ± 4

1.2 ± 0.6

5.5 ± 0.8

17 ± 5

  3 ± 4 4919 ± 3085

NORMALS (14) 2.2 ± 0.5 3.2 ± 0.8 53 ± 5 −58 ± 4 1.1 ± 0.1 3.5 ± 0.7 49 ±6   5 ± 1 7838 ± 105

*Mean ± SEM ( ) Patient number DT, detection threshold (in BU) RT,recognition threshold (in BU) ME, magnitude estimation (in %) H, hedonicvalue (in %) Shh (in pg/ml) Treated with respect to Untreated ^(a)p <0.001 ^(b)p < 0.005 ^(c)p < 0.02 ^(d)p < 0.05 Untreated with respect toNormals ^(a1)p < 0.001 Treated with respect to Normals ^(a2)p < 0.001^(d2)p < 0.05

indicates data missing or illegible when filed

TABLE 17 SUBJECTIVE RESPONSES TO ORAL THEOPHYLLINE TREATMENT IN HYPOSMICPATIENTS TREATED WITH ORAL THEOPHYLLINE NUMBER RESPONSE STUDIED RANGERESPONSE CONDITION [%] [%] Mean ± SEM SMELL FUNCTION (31) IMPROVED 19[61] 2-100 34 ± 6 MEN 11 3-95  27 ± 9 WOMEN 8 2-100  43 ± 17 NOTIMPROVED 12 [39] 0 0 FLAVOR FUNCTION (31) IMPROVED^(d) 19 [61] 1-100 43± 8 NOT IMPROVED 12 [39] 0 0 TASTE FUNCTION (31) IMPROVED^(b) 20 [64]

3-100 47 ± 8 NOT IMPROVED 11 [36] 0 0 [ ] % of patients studied ( )Patient number With respect to Not Improved ^(d)p < 0.05, X² (2.45)^(b)p < 0.01, X² (4.00)

indicates data missing or illegible when filed

TABLE 18 CHANGES IN SMELL FUNCTION AND IN NASAL MUCUS SONIC HEDGEHOG ANDAFTER TREATMENT WITH SEVERAL DOSES OF ORAL THEOPHYLLINE ORALTHEOPHYLLINE PYRIDINE NITROBENZENE DOSE (in mg) DT RT ME H DT RT ME H200 (6) 8.4 ± 0.8

9.8 ± 0.9 35 ± 15 −34 ± 13 8.8 ± 1.9 10.6 ± 0.8  12 ± 11 0.8 ± 0.8 400(6) 7.0 ± 1.8 7.8 ± 2.2 43 ± 12 −35 ± 15 5.0 ± 2.1 7.0 ± 2.6 28 ± 14  2± 10  600 (14) 5.2 ± 0.9

5.8 ± 1.1

50 ± 8  −10 ± 8  5.4 ± 1.5 5.6 ± 1.5

22 ± 7  2 ± 6 800 (5) 2.8 ± 1.2

4.0 ± 1.8

36 ± 15 −20 ± 13 3.2 ± 1.3

4.0 ± 1.5

28 ± 18 21 ± 20 UNTREATED (44) 7.8 ± 0.4 8.7 ± 0.4

−30 ± 4  8.0 ± 0.6 9.0 ± 0.5 17 ± 4  6 ± 5 *Mean ± SEM ( ) Patientnumber DT, detection threshold (in BU) RT, recognition threshold (in BU)ME, magnitude estimation (in %) H, hedonic value (in %) With respect toUntreated ^(a)p < 0.001 ^(b)p < 0.005 ^(c)p < 0.02 ^(d)p < 0.05

indicates data missing or illegible when filed

TABLE 19 CHANGES IN SMELL FUNCTION AND IN SONIC HEDGEHOG IN NASAL MUCUSIN HYPOSMIC MEN AND WOMEN BEFORE AND AFTER TREATMENT WITH ORALTHEOPHYLLINE CON- PYRIDINE NITROBENZENE DITION DT RT ME H DT RT ME H UN-TREATED MEN (24) 7.9 ± 8.7 ± 34 ± −27 ± 9.0 ± 9.9 ± 10 ± 4 ± 0.5* 0.5 55 0.7 0.6 3 3 WOMEN 7.9 ± 9.1 ± 33 ± −30 ± 7.3 ± 8.1 ± 16 ±

± (20) 0.7 0.8 9 8 1.0 1.0 6 2 TREATED MEN (19) 4.8 ± 5.6 ± 36 ± −30 ±4.8 ± 5.2 ± 19 ± 6 ± 0.9^(a) 1.0

7 7 1.1

5 5 WOMEN 7.1 ± 8.0 ± 42 ± −38 ± 6.8 ± 7.3 ± 25 ± 8 ± (12) 0.9 1.0 9 81.4 1.1 8 7 *Mean ± SEM ( ) Patient number DT, detection threshold (inBU) RT, recognition threshold (in BU) ME, magnitude estimation (in %) H,hedonic value (in %) With respect to Untreated State ^(a)p < 0.001 ^(b)p< 0.005 ^(c)p < 0.01

indicates data missing or illegible when filed

Example 11. Sonic Hedgehog in Human Taste Function

Purpose:

To determine the role of sonic hedgehog (Shh) in human taste function.

Background:

Shh is a 20 kD NH₂ terminal protein involved with signaling in multiplecellular systems. We hypothesized that Shh should be found in saliva.Thus, we attempted to measure Shh in saliva in both normal subjects andin patients with taste dysfunction.

Methods:

Shh was measured in parotid saliva of both normal subjects and patientswith taste dysfunction of multiple etiologies by use of sensitivespectrophotometric ELISA assay. Taste dysfunction was defined clinicallyby both subjective inhibition of taste function (including acuity loss)and impaired gustometry.

Results:

Shh was found in parotid saliva in each normal subject. It was alsofound in each patient with taste dysfunction but at levels significantlylower than in normal subjects. Patients expressed subjective loss oftaste function. Impaired gustometry was also measured.

Methods

Subjects

Normal Subjects.

Twenty-six volunteers, aged 22-84 y, 54±5 y (Mean±SEM) with normal tastefunction were studied. These volunteers were either patients who werepresented to The Taste and Smell Clinic in Washington, D.C. forevaluation of symptoms unrelated to taste loss or who were employees ofThe Taste and Smell Clinic who volunteered for the study. Subjects wereselected in a consecutive manner and included all subjects whovolunteered for the study.

Patients.

Sixty-four patients, aged 10-88 y, 56±3 y who presented to The Taste andSmell Clinic in Washington, D.C. for evaluation and treatment of tasteand smell loss were also studied. Patients were selected consecutivelyfrom patients evaluated at The Clinic from 2012-2013. Patients were 12men, aged 12-88 y, 54±4 y and 14 women, aged 10-84 y, 51±5 y. Tastedysfunction was caused by seven pathological events includingpost-influenza-like hypogeusia [(PIHH) 17 patients], allergic rhinitis[26 patients], congenital loss of smell with associated hypogeusia [10patients], head injury [12 patients], post general anesthesia [twopatients], dysgeusia and oropyrosis [one patient] and post systemicradiation [one patient]. All patients exhibited taste dysfunction asmeasured by subjective statement of acuity loss and by impairedgustometry.

Subjective statements of acuity loss were quantitated by use of a scalefrom 0-100 with 100 reflecting total loss of taste function, 0reflecting no loss and a number between 0-100 reflecting appropriatedegree of loss. Mean±SEM of loss degree was measured among all patientsand each pathology initiating taste dysfunction.

Gustometry measurements included measurements of detection (DT) andrecognition (RT) thresholds and magnitude estimation (ME) for fourtastants [NaCl (salt), sucrose (sweet), HCl (sour) and urea (bitter)].Abnormalities of taste function were measured by increased DT or RTabove normal (decreased sensitivity) and/or decreased ME (decreasedsensitivity) for one or more of the tastants presented.

Study protocol was consistent with studies previously approved by theInstitutional Review Board of the Georgetown University Medical Center.Each patient and subject agreed to participate in the study and signedan informed consent participation form.

Methods

Patients and volunteers collected saliva by placement of a Lashley cupover Stensen's duct of one parotid gland with saliva stimulated bylingual placement of concentrated lemon juice. Saliva was collected inplastic tubes in ice for timed periods of 8-10 min, as previouslydescribed. Flow rate was measured by mean flow over a four minute timeperiod, as previously described. Samples were stored at −20° C. untilanalyzed.

Each sample was analyzed by use of a sensitive spectrophotometric ELISAtechnique obtained from Abcam Inc. (Cambridge, Mass.). Analysis ofduplicate samples agreed within 5%. All analyses were made independentof the knowledge of the status of any subject. Only after all sampleswere analyzed were results tabulated and samples classified inrelationship to subject status.

Results were analyzed such that mean±SEM levels in each category wereobtained and results compared using Student t tests with p<0.05considered significant.

Results

Mean Shh was present in saliva in each normal volunteer and patientstudied (Table 20). Levels in patients were significantly lower thanthose measured in normal subjects (Table 20).

Shh in saliva did not differ in men or women patients (Table 21).

Shh in saliva demonstrated a pattern of increasing with age with thehighest levels demonstrated in the oldest patients studied (Table 22).

Mean Shh levels in patients with various etiologies related to the causeof their taste dysfunction varied widely (Table 23). The lowest levelwas demonstrated in the patient with dysgeusia and oropyrosis, thehighest levels in patients with PIHH (Table 23). While the mean level inall patients was significantly lower than in normal subjects levels inpatients with head injury were significantly lower than patients withPIHH.

Subjective loss of taste acuity was present in each patient with tastedysfunction with a mean loss of 41±3%. Subjective loss of flavorperception was present in each patient with a loss of 28±3%. Impairedgustometry were demonstrated in the patients with measurements ofincreased DT (decreased sensitivity), increased RT (decreasedsensitivity) and decreased ME (decreased sensitivity) compared tosimilar results in normal subjects (Table 24).

Discussion

Results of this study indicate that Shh is present in saliva in bothnormal subjects and in patients with taste dysfunction. Its presence inhuman saliva is herein reported for the first time.

As patients aged there was an increase in saliva Shh with the highestlevels demonstrated in the oldest patients.

Shh levels in untreated patients with taste dysfunction weresignificantly lower than in normal subjects similar to resultspreviously demonstrated for levels of saliva cAMP and which havepreviously been demonstrated to be significantly lower than in normalsubjects.

Salivary Shh levels were lower than normal in patients in all diagnosticcategories studied. This result suggests that lower than normal levelsof salivary Shh may serve as a general diagnostic value for tastedysfunction in patients with these symptoms.

TABLE 20 SONIC HEDGEHOG IN SALIVA IN NORMAL SUBJECTS AND IN PATIENTSWITH TASTE DYSFUNCTION SUBJECTS SONIC HEDGEHOG* NORMALS (26) 215 ± 7⁺PATIENTS (64)  63 ± 6^(a) ( ) Subject number *in pmol/ml ⁺Mean ± SEMWith respect to normals ^(a)p < 0.001

TABLE 21 SONIC HEDGEHOG IN SALIVA IN PATIENTS WITH TASTE DYSFUNCTIONCHARACTERIZED BY GENDER PATIENTS AGE (y) SONIC HEDGEHOG* MEN (37) 56 ± 3  61 ± 7⁺  WOMEN (30) 55 ± 4 62 ± 10 ( ) Subject number *in pmol/ml⁺Mean ± SEM

TABLE 22 SONIC HEDGEHOG IN SALIVA IN PATIENTS WITH TASTE DYSFUNCTIONCHARACTERIZED BY AGE PATIENTS SONIC HEDGEHOG* <30 (11)   66 ± 8⁺  31-40(4) 80 ± 24 41-50 (7) 63 ± 14 51-60 (9) 62 ± 10 61-70 (16) 90 ± 13 71-80(14) 96 ± 13 >81 (6) 104 ± 35  ( ) Subject number *in pmol/ml ⁺Mean ±SEM

TABLE 23 SONIC HEDGEHOG IN SALIVA OF PATIENTS WITH TASTE DYSFUNCTIONCONDITION SONIC HEDGEHOG* PIHH (17)   104 ± 16⁺  ALLERGIC RHINITIS (26)76 ± 6  CONGENITAL (10) 70 ± 11 HEAD INJURY (12) 54 ± 11 DYSGEUSIA WITHOROPYROSIS (1) 29 POST GENERAL ANESTHESIA (2) 77 POST RADIATION (1) 115 ( ) Subject number *in pmol/ml ⁺Mean ± SEM

TABLE 24 TASTE FUNCTION IN PATIENTS COMPARED TO NORMAL SUBJECTS NaClSucrose HCl UREA DT RT ME DT RT ME DT RT ME DT RT ME PATIENTS 3.9 ± 0.3

4.8 ± 0.6^(d) 52 ± 3.8 ± 0.3^(a) 3.9 ± 0.2^(a) 44 ± 6

3.8 ± 4.9 ± 49 ± 7^(d) 4.3 ± 0.5^(e) 5.3 ± 0.7^(d) 44 ± 7^(c) (18) 7 0.30.7 NORMALS 2.3 ± 0.1 3.1 ± 0.2  68 ± 2.5 ± 0.1  3.2 ± 0.1  69 ± 4 3.1 ±3.5 ± 68 ± 4  3.2 ± 0.1  3.4 ± 0.1  68 ± 4  (55) 4 0.2 0.1 RT,Recognition Threshold DT, Detection Threshold ME, Magnitude Estimation () Subject number ⁺Mean ± SEM With respect to normals ^(a)p < 0.001 ^(b)p< 0.005 ^(c)p < 0.01 ^(d)p < 0.02 ^(e)p < 0.05

indicates data missing or illegible when filed

Additional subjects were examined and the data reanalyzed in view of newdata.

Methods:

Shh was measured in parotid saliva of both normal subjects and inpatients with taste dysfunction of multiple etiologies by use of asensitive spectrophotometric ELISA assay. Taste dysfunction was definedclinically by both subjective changes of taste acuity and flavorperception and by impaired gustometry. Patients were treated with oraltheophylline 200-800 mg daily for 2-10 months with saliva Shh and tastefunction measured at intervals of 2-8 months.

Results:

Shh was found in parotid saliva in both normal subjects and in patientswith taste dysfunction but levels were significantly lower in patientsthan in normal subjects. Both subjective loss of taste acuity and flavorperception and impaired gustometry was measured in each patient.Theophylline treatment increased saliva Shh and improved both subjectivetaste function and gustometry.

Conclusions:

This is the first demonstration of Shh in saliva. Decreased saliva Shhsecretion can be considered a marker for taste dysfunction in patientswith multiple etiologies. Theophylline acts to increase Shh in salivaand thereby improve human taste dysfunction as its increase in nasalmucus improved human smell dysfunction.

Methods

Subjects

Normal Subjects.

Twenty-six volunteers, aged 22-84 y, 54±5 y (Mean±SEM) with normal tastefunction were studied. These volunteers were either patients whopresented to The Taste and Smell Clinic in Washington, D.C. forevaluation of symptoms unrelated to taste loss or who were employees ofThe Taste and Smell Clinic who volunteered for the study. Subjects wereselected in a consecutive manner and included all subjects whovolunteered for the study.

Patients.

Eighty-one patients, aged 10-88 y, 56±3 y who presented to The Taste andSmell Clinic in Washington, D.C. for evaluation and treatment of tasteand smell loss were also studied. Patients were selected consecutivelyfrom patients evaluated at The Clinic from 2012-2013. Patients were 58men, aged 12-88 y, 54±4 y and 56 women, aged 10-84 y, 51±5 y. Tastedysfunction was caused by seven pathological events includingpost-influenza-like hypogeusia [(PIHH) 20 patients], allergic rhinitis[31 patients], congenital loss of smell with associated hypogeusia [9patients], head injury [14 patients], post general anesthesia [threepatients], dysgeusia with oropyrosis [one patient] and post systemicradiation [one patient]. All patients exhibited taste dysfunction asmeasured by subjective statement of taste acuity loss and loss of flavorperception and by impaired gustometry.

Subjective statements of taste acuity loss and loss of flavor perceptionwere quantitated by use of a scale from 0-100 with 100 reflecting totalloss of taste acuity or flavor perception, 0 reflecting no loss and anumber between 0-100 reflecting appropriate degree of loss. Some ofthese patients also exhibited taste distortions but these results werenot the subject matter for this study and are not included in thisstudy. Mean±SEM of loss degree was measured among all patients and eachpathology initiating taste dysfunction.

Gustometry measurements included measurements of detection (DT) andrecognition (RT) thresholds and magnitude estimation (ME) for fourtastants [NaCl (salt), sucrose (sweet), HCl (sour) and urea (bitter)].Abnormalities of taste function were measured by increased DT or RTabove normal (decreased sensitivity) and/or decreased ME (decreasedsensitivity) for one or more of the tastants presented.

Treatment with oral theophylline was administered to 79 of thesepatients, aged 12-86 y, 41 men and 38 women at doses of 200-1000 mg forperiods of 2-10 months. Saliva Shh and measurements of taste function byuse of subjective responses of acuity and flavor perception and inolfactometry was measured at intervals of 2-6 months in these patients.

Study protocol was consistent with studies previously approved by theInstitutional Review Board of the Georgetown University Medical Center.Each patient and subject agreed to participate in the study and signedan informed consent participation form. All subjects under age 18 yentered into the study after a parent gave informed consent.

Methods

Parotid saliva was collected in patients and normal volunteers byplacement of a Lashley cup over Stensen's duct of one parotid gland withsaliva stimulated by lingual, timed placement of concentrated lemonjuice. Saliva was collected in plastic tubes in ice for timed periods of8-10 min, as previously described. Flow rate was measured by mean flowover a four minute time period, as previously described. Samples werestored at −20° C. until analyzed.

Each sample was analyzed by use of a sensitive spectrophotometric ELISAtechnique obtained from Abcam Inc. (Cambridge, Mass.). Analysis ofduplicate samples agreed within 5%. All analyses were made independentof the knowledge of the status of any subject. Only after all sampleswere analyzed were results tabulated and samples classified inrelationship to subject status.

Results were analyzed such that mean±SEM levels in each category wereobtained and results compared using Student t tests with p<0.05considered significant.

Results

Shh was present in parotid saliva in each normal volunteer and in eachuntreated patient with hypogeusia (Table 25). Levels in patients weresignificantly lower than those measured in normal subjects (Table 25).

Shh in saliva did not differ in untreated men or women patients (Table26).

Shh in saliva demonstrated a varying pattern with age (Table 27).

Mean Shh levels in patients with various etiologies related to the causeof their taste dysfunction varied widely (Table 28). The lowest levelwas present in one patient with dysgeusia (distorted taste sensation)and oropyrosis, the highest levels in patients post anesthesia (Table28). The mean level in each patient category was significantly lowerthan the mean level in normal subjects.

Subjective loss of taste acuity and flavor perception was present ineach patient before treatment with oral theophylline. Impairedgustometry were demonstrated in patients with measurements of increasedDT (decreased sensitivity), increased RT (decreased sensitivity) anddecreased ME (decreased sensitivity) compared to similar results innormal subjects (Table 29).

After treatment with oral theophylline Shh increased in parotid salivato levels above those in normal subjects or in untreated patients (Table30). There was improvement in both subjective taste acuity and flavorperception in about 60% of patients (Table 31). Degree of return ofacute acuity and flavor perception was greater in women than in men.Improvement in olfactometry also occurred (data not shown).

Discussion

Results of this study indicate that Shh is present in saliva in bothnormal subjects and in patients with taste dysfunction. Its presence inhuman saliva is herein reported for the first time.

Salivary Shh levels were lower than normal in patients in all diagnosticcategories studied. This result suggests that lower than normal levelsof salivary Shh may serve as a general diagnostic marker for tastedysfunction in patients with these symptoms.

TABLE 25 SONIC HEDGEHOG IN PAROTID SALIVA IN NORMAL SUBJECTS AND INPATIENTS WITH TASTE DYSFUNCTION SUBJECTS SONIC HEDGEHOG* NORMALS (26)  184 ± 12⁺ PATIENTS (81)  64 ± 6^(a) ( ) Subject number *in pmol/ml⁺Mean ± SEM With respect to normals ^(a)p < 0.001

TABLE 26 SONIC HEDGEHOG IN PAROTID SALIVA IN NORMAL SUBJECTS AND INUNTREATED PATIENTS WITH TASTE DYSFUNCTION CHARACTERIZED BY GENDER SONICAGE (y) HEDGEHOG* NORMAL SUBJECTS MEN (10) 70 ± 6   186 ± 16⁺ WOMEN (17)61 ± 4 180 ± 12 PATIENTS MEN (41) 56 ± 3 76 ± 7 WOMEN (40) 55 ± 4 66 ± 6( ) Subject number *in pmol/ml ⁺Mean ± SEM

TABLE 27 SONIC HEDGEHOG IN SALIVA IN PATIENTS WITH TASTE DYSFUNCTIONCHARACTERIZED BY AGE PATIENTS‡ SONIC HEDGEHOG* <30 (11)   62 ± 9⁺  31-40(5) 76 ± 19 41-50 (5) 56 ± 12 51-60 (11) 57 ± 9  61-70 (22) 76 ± 8 71-80 (15) 93 ± 13 >81 (7) 62 ± 24 ‡Age (in years) ( ) Patient number*in pmol/ml ⁺Mean ± SEM

TABLE 28 SONIC HEDGEHOG IN SALIVA OF UNTREATED PATIENTS WITH TASTEDYSFUNCTION CONDITION SONIC HEDGEHOG* PIHH (27)   58 ± 10^(+a) ALLERGICRHINITIS (26) 70 ± 6^(a)  CONGENITAL (10) 76 ± 11^(a) HEAD INJURY (14)49 ± 10^(a) DYSGEUSIA WITH OROPYROSIS (1) 29 POST GENERAL ANESTHESIA (2)82 POST RADIATION (1) 145 ( ) Patient number *in pmol/ml ⁺Mean ± SEMWith respect to normals ^(a)p < 0.001

TABLE 29 TASTE FUNCTION IN UNTREATED HYPOGEUSIC PATIENTS COMPARED TONORMAL SUBJECTS BY USE OF GUSTOMETRY NaCl SUCROSE HCl UREA DT RT ME DTRT ME DT RT ME DT RT ME PA- 3.9 ± 0.3

4.8 ± 0.6

52 ± 7 3.8 ± 0.3^(a) 3.9 ± 0.2^(a) 44 ± 6

3.8 ± 0.3 4.9 ± 0.7 49 ± 7

4.3 ± 0.5

5.3 ± 0.7^(d) 44 ± 7^(c) TIENTS (64) NOR - 2.3 ± 0.1 3.1 ± 0.2 68 ± 42.5 ± 0.1  3.2 ± 0.1  69 ± 4 3.1 ± 0.2 3.5 ± 0.1 68 ± 4 3.2 ± 0.1 3.4 ±0.1  68 ± 4  MALS (26) RT, Recognition Threshold DT, Detection ThresholdME, Magnitude Estimation ( ) Subject number ⁺Mean ± SEM With respect tonormals ^(a)p < 0.001 ^(b)p < 0.005 ^(c)p < 0.01 ^(d)p < 0.02 ^(e)p <0.05

indicates data missing or illegible when filed

TABLE 30 SALIVA SONIC HEDGEHOG IN HYPOGEUSIC PATIENTS BEFORE AND AFTERTREATMENT WITH ORAL THEOPHYLLINE SALIVA PATIENTS SONIC HEDGEHOG* BEFORETREATMENT (66)     71 ± 4^(+,a) AFTER TREATMENT (66) 199 ± 20 MEN (61)180 ± 15 WOMEN (58) 213 ± 33 ( ) Patient number *in pmol/ml ⁺Mean ± SEMWith respect to pretreatment ^(a)p < 0.001

TABLE 31 CHANGES IN TASTE FUNCTION IN PATIENTS AFTER TREATMENT WITH ORALTHEOPHYLLINE IMPROVE- DEGREE OF PATIENT MENT IMPROVEMENT PATIENTS NUMBERNUMBER (%) TASTE ACUITY 79 45 (63)   28 ± 4⁺ MEN 38 21 (55) 20 ± 5 WOMIN41 24 (59) 35 ± 6 FLAVOR PERCEPTION 79 45 (63) 24 ± 4 MEN 38 22 (58) 18± 4 WOMEN 41 23 (54) 36 ± 6 ( ) Patient number ⁺Mean ± SEM

Example 12. Sonic Hedgehog in Patients with Taste Dysfunction: Beforeand after Treatment with Oral Theophylline

Methods:

After treatment with oral theophylline, Shh was measured in parotidsaliva of patients with taste dysfunction of multiple etiologies by useof sensitive spectrophotometric ELISA assay. Taste dysfunction wasdefined clinically by impaired gustometry.

Results:

Shh was found in parotid saliva in each subject, but was significantlylower in patients with taste dysfunction. Tables 20, 25, and 32.Patients treated with oral theophylline improved subjectively in tastefunction.

Methods

Subjects

Normal Subjects.

Forty-three patients were treated with oral theophylline at doses of200-800 mg for periods of 2-10 months, at which time their smellfunction was evaluated by olfactometry and by SHH measurements in nasalmucus by use of a sensitive spectrophotometric ELISA assay.

These volunteers were either patients who were presented to The Tasteand Smell Clinic in Washington, D.C. for evaluation of symptomsunrelated to taste loss or who were employees of The Taste and SmellClinic who volunteered for the study. Subjects were selected in aconsecutive manner and included all subjects who volunteered for thestudy.

Patients.

Forty-three patients were presented to The Taste and Smell Clinic inWashington, D.C. for evaluation and treatment of taste and smell loss.Taste dysfunction was caused by seven pathological events includingpost-influenza-like hypogeusia [(PIHH) 13 patients], allergic rhinitis[15 patients], congenital loss of smell with associated hypogeusia [8patients], head injury [4 patients], post general anesthesia [twopatients], and post systemic radiation [one patient]. All patientsexhibited a decreased Shh level.

Gustometry measurements included measurements of detection (DT) andrecognition (RT) thresholds and magnitude estimation (ME) for fourtastants [NaCl (salt), sucrose (sweet), HCl (sour) and urea (bitter)].Abnormalities of taste function were measured by increased DT or RTabove normal (decreased sensitivity) and/or decreased ME (decreasedsensitivity) for one or more of the tastants presented.

Study protocol was consistent with studies previously approved by theInstitutional Review Board of the Georgetown University Medical Center.Each patient and subject agreed to participate in the study and signedan informed consent participation form.

Methods

Patients and volunteers collected saliva by placement of a Lashley cupover Stensen's duct of one parotid gland with saliva stimulated bylingual placement of concentrated lemon juice. Saliva was collected inplastic tubes in ice for timed periods of 8-10 min, as previouslydescribed. Flow rate was measured by mean flow over a four minute timeperiod, as previously described. Samples were stored at −20° C. untilanalyzed.

Each sample was analyzed by use of a sensitive spectrophotometric ELISAtechnique obtained from Abcam Inc. (Cambridge, Mass.). Analysis ofduplicate samples agreed within 5%. All analyses were made independentof the knowledge of the status of any subject. Only after all sampleswere analyzed were results tabulated and samples classified inrelationship to subject status.

Results were analyzed such that mean±SEM levels in each category wereobtained and results compared using Student t tests with p<0.05considered significant.

Results

Shh was present in saliva in each patient studied however variousetiologies related to the cause of their taste dysfunction varied widely(Table 32). Levels in patients were significantly lower than thosemeasured in normal subjects (Tables 20 and 25).

The lowest level was demonstrated in the patient with congenital, thehighest levels in patients with Anesthesia Induced (Table 32).

Impaired gustometry were demonstrated in the patients with measurementsof increased DT (decreased sensitivity), increased RT (decreasedsensitivity) and decreased ME (decreased sensitivity) compared tosimilar results in normal subjects (Tables 20, 25, and 33).Surprisingly, treatment with theophylline increased levels of Shh byalmost 2 fold while improving gustometric functions (Table 33).

Discussion

Results of this study indicate that Shh is increased in saliva inpatients with taste dysfunction as a result of theophylline treatment.Theophylline also improved gustometric functions of treated patients.

TABLE 32 SALIVA SONIC HEDGEHOG IN PATIENTS ATTER ORAL THEOPHYLLINESALIVA SONIC HEDGEHOG CONDITION (pmol/ml)) ANESTHESIA INDUCED (2) 151ALLERGIC RHINITIS (26)   212 ± 14⁺ CONGENITAL (10) 132 ± 23 HEAD INJURY(14) 115 ± 15 PIHH (27) 210 ± 12 POST RADIATION (1) 145 ( ) Patientnumber ⁺Mean ± SEM

TABLE 33 TASTE FUNCTION AND SONIC HEDGEHOG IN SALIVA IN PATIENTS WITHTASTE DYSFUNCTION BEFORE AND AFTER TREATMENT WITH THEOPHYLLINE SALIVASONIC NaCl SUCROSE SCl UREA HEDGEHOG CONDITION DT RT ME DT RT ME DT RTME DT RT ME (pmol/ml) UNTREATED 3.9 ± 0.3⁺ 4.8 ± 0.6 52 ± 7 3.8 ± 0.33.9 ± 0.2 44 ± 6 3.8 ± 0.3 4.9 ± 0.7 49 ± 7 4.3 ± 0.5 5.3 ± 0.7 44 ± 763 ± 6 (81) THEOPHYLLINE 3.4 ± 0.2   3.6 ± 0.2 58 ± 5 3.3 ± 0.2 3.6 ±0.2 49 ± 5 3.6 ± 0.2 3.7 ± 0.3 54 ± 5 3.9 ± 0.3 3.9 ± 0.3 54 ± 5 102 ±10 TREATED (81) RT, Recognition Threshold DT, Detection Threshold ME,Magnitude Estimation ( ) Subject number ⁺Mean ± SEM

Example 13. Diagnosing Patients with Loss and/or Distortion of Taste orSmell

Bodily fluids will be used to measure the levels of one or more membersof the hedgehog signaling pathway. For example, in one example, a salivasample or a mucus sample will be extracted from a patient and preparedfor analysis as described throughout. Levels of SHH, DHH, and IHH, willthen be measured by and an antibody-based method, such as an ELISAassay.

The levels of members of the hedgehog signaling pathway in patientsexhibiting loss and/or distortion of taste or smell (e.g., hyposmia,dysosmia, anosmia, phantosmia, hypogeusia, dysgeusia, phantogeusia,and/or ageusia) will be lower than normal controls. For example, inpatients suffering from loss and/or distortion of taste or smell, thelevel of SHH, in some cases, will be or about: 0 pg/mL, greater than 0pg/mL to less than less than 1 pg/mL, 1 pg/mL to 25 pg/mL, 15 pg/mL to30 pg/mL, 20 pg/mL to 40 pg/mL; 35 pg/mL to 50 pg/mL; 45 pg/mL to 100pg/mL; 75 pg/mL to 150 pg/mL, 125 pg/mL to 1000 pg/mL, 900 pg/mL to 2500pg/mL, 2000 pg/mL to 5000 pg/mL, 4000 pg/mL to 7500 pg/mL, 6000 pg/mL to10,000 pg/mL; (b) the level of IHH can be or about: 0 pg/mL, greaterthan 0 pg/mL to 0.1 pg/mL, 0.05 pg/mL to 0.15 pg/mL, 0.125 pg/mL to 0.2pg/mL, 0.15 pg/mL to 0.30 pg/mL, 0.25 pg/mL to 0.5 pg/mL, 0.4 pg/mL to0.7 pg/mL, 0.6 pg/mL to 0.75 pg/mL, 0.725 pg/mL to 0.9 pg/mL, 0.8 pg/mLto 1.0 pg/mL, less than 1.0 pg/mL, less than 0.05 ng/mL, less than 0.15ng/mL, less than 0.2 ng/mL, less than 0.3 ng/mL, less than 0.5 ng/mL,less than 0.7 ng/mL, less than 0.75 ng/mL, less than 0.9 ng/mL, lessthan 1.0 ng/mL, less than 1.1 ng/mL, less than 1.5 ng/mL, less than 1.75ng/mL, less than 2.0 ng/mL, less than 2.25 ng/mL, less than 5.0 ng/mL,less than 6.0 ng/mL, less than 7.0 ng/mL, less than 10.0 ng/mL, or lessthan 100.0 ng/mL; (c) the level of DHH can be or about: 0 pg/mL, greaterthan 0 pg/mL to 0.1 pg/mL, 0.05 pg/mL to 0.15 pg/mL, 0.125 pg/mL to 0.2pg/mL, 0.15 pg/mL to 0.30 pg/mL, 0.25 pg/mL to 0.5 pg/mL, 0.4 pg/mL to0.7 pg/mL, 0.6 pg/mL to 0.75 pg/mL, 0.725 pg/mL to 0.9 pg/mL, 0.8 pg/mLto 1.0 pg/mL, 0.9 pg/mL to 1.1 pg/mL, 1.0 pg/mL to 1.3 pg/mL, 1.2 pg/mLto 1.5 pg/mL, 1.4 pg/mL to 2.0 pg/mL, 1.9 pg/mL to 2.5 pg/mL, 2.4 pg/mLto 3.0 pg/mL, 2.9 pg/mL to 3.5 pg/mL, 3.4 pg/mL to 3.8 pg/mL, 3.7 pg/mLto 3.9 pg/mL, 3.85 pg/mL to 5.0 pg/mL, less than 5.0 pg/mL, less than0.05 ng/mL, less than 0.15 ng/mL, less than 0.2 ng/mL, less than 0.3ng/mL, less than 0.5 ng/mL, less than 0.7 ng/mL, less than 0.75 ng/mL,less than 0.9 ng/mL, less than 1.0 ng/mL, less than 1.1 ng/mL, less than1.5 ng/mL, less than 1.75 ng/mL, less than 2.0 ng/mL, less than 2.25ng/mL, less than 5.0 ng/mL, less than 6.0 ng/mL, less than 7.0 ng/mL,less than 10.0 ng/mL, or less than 100.0 ng/mL. However, there can besome inter-patient variability because the levels of the differentmembers of the hedgehog signaling pathway vary based on the person.

In normal controls, the levels of SHH, IHH, and DHH, will be higher, andin some cases can be significantly higher, than the levels of patientswith loss and/or distortion of taste or smell. In most cases, thethreshold level can be an average level for one or more members of thehedgehog signaling pathway as measured in a control populationcomprising subjects with normal olfactory and/or gustatory function.

In some cases, the threshold level can be an average level for one ormore members of the hedgehog signaling pathway as measured in the samesubject before exhibiting loss and/or distortion of taste or smell. Forexample, with the advent of personalized medicine, a basal level of oneor more members of the hedgehog signaling pathway can be known prior toa subject being diagnosed with loss and/or distortion of taste or smell.

In another example, the level of one or more members of the hedgehogsignaling pathway is at least one order of magnitude lower than saidthreshold level. For example, 2 or more orders of magnitude lower thansaid threshold level.

Other markers will be measured from the biological samples obtained fromthe patients with loss and/or distortion of taste or smell. For example,pro-inflammatory cytokines (e.g., IL-la, IL-1β, IL-6, IL-18, TNF-α, orany combination thereof) can be measured as previously described.Additional markers can be measured including but are not limited toanti-inflammatory cytokines (e.g., IL-1ra, IL-10, IFN-γ, IFN-β, orcombinations thereof), immunoglobulin E (IgE), eosinophils, cyclicadenosine monophosphate (cAMP), cyclic guanosine monophosphate (cGMP),nitric oxide (NO), IL-1 RII, IL-2R, or any combination thereof. Theseadditional markers can be used to assess if patients have loss and/ordistortion of taste or smell.

Additionally, any combination of the markers can be used to assess theseverity of a patient's loss and/or distortion of taste or smell. Forexample, if a patient has little to no measureable levels of one or moremarkers, the patient can be diagnosed as having a severe case of lossand/or distortion of taste or smell. The threshold level can be anaverage level for one or more markers as measured in a controlpopulation comprising subjects with normal olfactory and/or gustatoryfunction. In some cases, the threshold level can be an average level forone or more markers as measured in the same subject before exhibitingloss and/or distortion of taste or smell. In another example, the levelof one or more markers is at least one order of magnitude lower thansaid threshold level, for example, 2 or more orders of magnitude lowerthan said threshold level.

For all the patients, the test subject's gustatory and/or olfactoryfunction can be determined by detecting a threshold (DT) score, arecognition threshold (RT) score, a magnitude estimation (ME) score, orany combination thereof with a forced-choice, three-stimuli,stepwise-staircase technique using one or more olfaction testingcompounds.

In some cases, the diagnosed result, e.g., loss and/or distortion oftaste or smell can be transferred via a communication medium. Exemplarytypes of communication media can include, but are not limited towritten, printed, and electronic types of media.

In other cases, a computer can implement the diagnosis of loss and/ordistortion of taste or smell. The computer can be a specialty computer,designed specifically for the task at hand.

Example 14: Treating Patients with Loss and/or Distortion of Taste orSmell

Patients diagnosed with loss and/or distortion of taste or smell will betreated using a variety of methods. For example, patients can be treatedwith a non-selective PDE inhibitor, a PDE-1 selective inhibitor, a PDE-2selective inhibitor, a PDE-3 selective inhibitor, a PDE-4 selectiveinhibitor, a PDE-5 selective inhibitor, a PDE-10 selective inhibitor, orany combination thereof.

To treat loss and/or distortion of taste or smell, some of the patientsreceiving a non-selective PDE inhibitor, can be given a methylxanthinederivative, including but not limited to caffeine, theophylline,doxophylline, cipamphylline, neuphylline, pentoxiphylline, ordiprophylline. Some patients receiving a PDE 1 inhibitor can be givenvinpocetine, compound KS505a, bepril, flunarizine, amiodarone,zaprinast, 8-methoxymethyl IPMX, SCH 51866, Nimodipine, or IC224. Somepatients receiving a PDE 2 inhibitor can be given EHNA. Some patientsreceiving a PDE 3 inhibitor can be given enoximone, milrinone(Primacor), amrinone, cilostamide, cilostazol (Pletal), trequinsin,inamrinone, anagrelide, pimobendan, lixazinone, or dihydro-pyridazinone.Some patients receiving a PDE 4 inhibitor can be given mesembrine,rolipram, ibudilast, roflumilast (Daxas), cilomilast (Airflo),piclamilast, luteolin, drotaverine, or denbufylline. Some patientsreceiving a PDE 5 inhibitor can be given sildenafil, tadalafil,vardenafil, udenafil and avanafil, dipyridamole, icariin,4-Methylpiperazine, Pyrazolo Pyrimidin-7-1, cilomilast, or zaprinast.Some patients receiving a PDE 6 inhibitor can be given zaprinast,dipyridamole, vardenafil, or tadalafil. Some patients receiving a PDE 7inhibitor can be given quinazoline type PDE7 inhibitor, dipyridamole, orthiadiazole. Some patients receiving a PDE 8 inhibitor can be givendipyridamole. Some patients receiving a PDE 9 inhibitor can be givenzaprinast. Some patients receiving a PDE 10 inhibitor can be givenpapaverine, OMS824 (from Omeros Corporation), and/or PF-2545920 (fromPfizer). Some patients receiving a PDE 11 inhibitor can be giventadalafil, zaprinast, or dipyridamole.

In some cases, patients can be given forskolin to treat loss and/ordistortion of taste or smell. In other cases, patients can be giventheophylline to treat loss and/or distortion of taste or smell. Becausedifferent patients react differently to forskolin and/or theophylline,patients can be given an optimal amount of the respective drugs. Forexample, forskolin can be given and/or present in an amount of less than500 mg to greater than 0 mg, or any amount in between. In other cases,theophylline can be given and/or present in an amount of less than 45 mgor about 20 μg, or any amount in between.

In some cases, patients can be given riociguat. In many case, low levelsof riociguat can be given to patients. For example, riociguat can begiven and/or present in an amount of greater than 0.0 μg to less than250 μg, or any amount in between.

Patients can be also given a variety of other therapeutic agents. Forexamples, cytochrome p450 inhibitors can be given to patients.

Patients can be also given β-adrenergic agonists, including but notlimited to β₁-adrenergic agonist, β₂-adrenergic agonist, anduncharacterized β-adrenergic agonists. For example, patients can begiven a β₁-adrenergic agonist selected from a group consisting ofdobutamine, isoproterenol, xamoterol, and epinephrine; a β₂-adrenergicagonist selected from a group consisting of albuterol, levalbuterol,fenoterol, formoterol, isoproterenol (β₁ and β₂), metaproterenol,salmeterol, terbutaline, clenbuterol, isoetarine, pirbuterol,procaterol, ritodrine, and epinephrine; and/or a uncharacterizedβ-adrenergic agonists selected from a group consisting of arbutamine,befunolol, bromoacetylalprenololmenthane, broxaterol, cimaterol,cirazoline, denopamine, dopexamine, etilefrine, hexoprenaline,higenamine, isoxsuprine, mabuterol, methoxyphenamine, nylidrin,oxyfedrine, prenalterol, ractopamine, reproterol, rimiterol,tretoquinol, tulobuterol, zilpaterol, and zinterol.

Patients can be also given anti-inflammatory cytokines, including butnot limited to IL-1ra, IL-10, IFN-γ, IFN-3, or any combination thereof.

Patients can be also given antibody, antibody fragment, or antibodymimetic that can inhibit one of the one or more pro-inflammatorycytokines. For example, the antibody fragments that can be given to apatient can be FAB fragments, FAB2 fragments, Fv fragments, ScFvfragments, antibody light chains, or antibody heavy chains. Antibodymimetics given to patients can include an affibody molecule, an affilin,an affitin, an anticalins, an avimers, a DARPins, a fynomer, a Kunitzdomain peptide, or a monobody.

In many cases, the therapeutic agents given to the patients can besteroid-free.

Some patients can be treated for loss and/or distortion of taste orsmell, e.g., hyposmia, dysosmia, anosmia, phantosmia, hypogeusia,dysgeusia, phantogeusia, and/or ageusia by altering the levels ofmembers of the hedgehog signaling pathway. For example, patients can begiven an effective amount of one or more members of the hedgehogsignaling pathway. In some cases, patients can be given an effectiveamount of the one or more exogenous members of the hedgehog signalingpathway. These members (e.g., RNA or protein) can be made in vitro or invivo by known methods.

Alternatively, patients can be treated for loss and/or distortion oftaste or smell by activating the expression of an effective amount ofone or more members of the hedgehog signaling pathway. In some cases,genetic manipulation responsible for the expression of one or moremembers of the hedgehog signaling pathway can be performed in vitro orin vivo. For example, promoter regions can be activated to increase theexpression of one or more members of the hedgehog signaling pathway.This can include, but not limited to methods such as gene therapy. Inother cases, activated expression can be effectuated through atherapeutic agent. Additionally, the treatment can directly orindirectly affect levels of one or more members of the hedgehogsignaling pathway.

In many cases, the patients can be given any combination treatment. Anyof the previously mentioned therapeutic agents and/or methods can begiven in combinations of two or more. This in some cases will producesynergistic effects.

Example 15: Treating Disease with cGMP Activators and/or cAMP Activators

To ameliorate loss and/or distortion of taste or smell in patients inneed thereof, patients can be given one or more cGMP activators, one ormore cAMP activators, or any combination thereof.

The patients can be given a cGMP activators selected from a groupconsisting of 3-(5′-hydroxymethyl-2′-furyl)-1-benzylindazole (YC-1),YC-1 derivatives, anthranilic acids derivatives, ataciguat (HMR1766),benzydamine analogs, CFM1517, A-350619, nitrovasodilators, molsidomine,nitroxyl (HNO), BAY 41-2272, BAY 41-8543, BAY 58-2667, cinaciguat (BAY58-2667), and riociguat (BAY 63-2521).

Sometimes the patients can be given a cAMP activators selected from agroup consisting of 3-(5′-hydroxymethyl-2′-furyl)-1-benzylindazole(YC-1), glucagon, PDE inhibitors, prostaglandin E1 (PGE1;pharmaceutically known as alprostadil), forskolin, and β-adrenergicagonists.

In many cases, giving a patient one or more cAMP activator and/or one ormore cAMP activators will ameliorate loss and/or distortion of taste orsmell in patients so diagnosed.

In many cases, the patients can be given any combination treatment. Anyof the previously mentioned therapeutic agents and/or methods can begiven in combinations of two or more. This in some cases producessynergistic effects.

Example 16: Alternative Formulations

The previously described therapeutic agents, individually or incombination, can be formulated so that they can be suitable foradministration by a method selected from a group consisting of: oraladministration, transmucosal administration, buccal administration,inhalation administration, intranasal administration, parentaladministration, intravenous administration, subcutaneous administration,intramuscular administration, sublingual administration, transdermaladministration, and rectal administration. In this case, for ease ofdelivery to the target site, the therapeutic agents can be formulated assuitable for intranasal and oral administration.

Different excipients can be used for the different formulations. Forexample, sweeter excipients can be used to mask bitterness with whilebinders can be used to form tablets.

Patients can be given a liquid form of the therapeutic agent, suitablefor intranasal and oral administration. The pH of the liquid therapeuticagent can be adjusted because the pH can play a role in efficacy. The pHcan be, for example, about: 6.0 to about 8.0, or any amount in between.

Example 17: Treating Disease with Low Levels of Ricociguat

Patients who exhibit pulmonary hypertension, e.g., thromboembolicpulmonary hypertension and pulmonary arterial hypertension, can betreated with an intranasal formulation of riociguat. Patients with otherdiseases such as bone related disorders, loss and/or distortion of tasteor smell can be also treated with intranasal formulations of riociguat.

The intranasal formulation contains lower and sometimes significantlylower amounts of riociguat. For example, patients can be given anintranasal formulation of riociguat, wherein riociguat can be present inan amount of greater than 0.0 μg to less than about 250 μg, or anyamount in between. Other patients can be given an intranasal formulationof riociguat wherein riociguat can be present in an amount of about lessthan 250 μg to greater than 0, or any amount in between.

Some patients can be also treated with non-intranasal inhalationaland/or intravenous formulations of riociguat because the effectivedosage of riociguat for inhalational and/or intravenous formulationsrequire significantly lower amounts of riociguat.

In many cases, the patients can be given any combination treatment. Anyof the previously mentioned therapeutic agents and/or methods can begiven in combinations of two or more. This in some cases can producesynergistic effects.

Example 18: Sonic Hedgehog Levels During Cilostazol and RoflumilastTreatment

Patients were given oral doses of roflumilast alone and the patients'nasal mucus was isolated and measured for sonic hedgehog levels. Forexample, Patient ID No. 11, was given 500 micrograms of daliresp(roflumilast) orally once per day for 4 months. Sonic hedgehog levelswere presented at 6665 ng/mol, which is within the levels measured withtheophylline treatment alone.

Patients were also given oral doses of cilostazol alone and thenmeasured for nasal mucosal sonic hedgehog levels. For example, PatientID No. 7, was given 100 mg of cilostazol one per day orally for 4months. Sonic hedgehog levels were present at a mean of 769 ng/mol,which is also within levels previously measured for theophyllinetreatment alone.

Treatment with both oral theophylline and cilostazol levels reveal asonic hedgehog level of a mean of 520 ng/mol. Similar values weremeasured with oral theophylline and roflumilast. As with oraltheophylline values varied a great deal but they were all significantlyhigher than before the drugs were administered.

Table 34 provides the raw data from these studies. Regarding the termsin the following data, “AR” can refer to allergic rhinitis. “PIHH” canrefer to post-influenza-like hyposmia and hypogeusia. “C” can refer tocongenital. “HI” can refer to head injury. “A” can refer toanesthesia-induced. “I” can mean idiopathic. Patient names were blockedout for privacy.

Example 19: Treating Appetite Loss

Patients exhibiting appetite loss are treated with one or moretherapeutic agents. For example, PDE inhibitors are used to treatappetite loss. The one or more PDE inhibitors can be a non-selective PDEinhibitor, a PDE-1 selective inhibitor, a PDE-2 selective inhibitor, aPDE-3 selective inhibitor, a PDE-4 selective inhibitor, a PDE-5selective inhibitor, a PDE-10 selective inhibitor, or any combinationthereof. In particular, patients are treated with a non-selective PDEinhibitor, e.g., theophylline.

The subjects chosen for this study are subjects that are experiencingappetite loss associated with having Addison's disease, amyloidosis,asthma, cancer, cat scratch disease, acute lymphoblastic leukemia,coxsackie virus, dementia, depression, encopresis, gastroespophagealreflux disease, acid reflux, infectious mononucleosis, kidney failure,legionnaires' disease, leigh's disease, peptic ulcer, postpartumdepression, psychotic disorders, rheumatoid arthritis, rocky mountainspotted fever, stress, anthrax, anorexia nervosa, pernicious anemia,alcohol withdrawal, migraine headaches, vitamin B12 deficiency, acutemountain sickness, stroke, thyroid diseases, yellow fever, liverdisease, chronic obstructive pulmonary disease, heart failure,hepatitis, HIV, pregnancy, bowel disease, disease of thegastrointestinal tract (e.g., gallbladder disease, crohn's disease,irritable bowel syndrome, appendicitis), brain damage (e.g., fromtrauma), hormone (endocrine) disease, inflammation (e.g., from chronicinfectious or chronic inflammatory diseases, or loss of taste. Othersubjects that are part of the treatment group are subjects that areexperiencing appetite loss associated with taking medication or drugs(e.g., including but not limited to digoxin, cocaine, codeine, demerol,morphine, antibiotics, amphetamines, methamphetamine, chemotherapyagents, common cold medicines, and cough & stuffy nose decongestants).Other subjects included in this study are those subjects that areexperiencing appetite loss associated with infections such as flu,mumps, syphilis, vasculitis, giardiasis, listeriosis, AIDS/HIV,pneumonia, chickenpox, strep throat, yellow fever, typhoid fever,leishmaniasis, gastroenteritis, mononucleosis, schistosomiasis, catscratch fever, coxsackie disease, hookworm disease, Rocky Mountainspotted fever, and food poisoning˜E. coli enteritis.

Treatment varies based on the disease and the severity of the conditionsof the subject in need thereof. A physician will determine theappropriate dose of PDE inhibitor or other drugs that can be effectivein treating appetite loss.

After treatment, body weight will increase from pretreatment levelsafter treatment with one or more therapeutic agents, e.g., PDE inhibitortreatment, such as with theophylline treatment.

While preferred embodiments of the present invention have been shown anddescribed herein, it will be obvious to those skilled in the art thatsuch embodiments can be provided by way of example only. Numerousvariations, changes, and substitutions will now occur to those skilledin the art without departing from the invention. It should be understoodthat various alternatives to the embodiments of the invention describedherein can be employed in practicing the invention.

What is claimed is: 1-64. (canceled)
 65. A method comprising detecting alevel of sonic hedgehog (SHH) in a biological sample from a subject bycontacting the biological sample with an anti-SHH antibody and detectingbinding between SHH and the anti-SHH antibody, wherein the biologicalsample comprises nasal mucus, saliva, or a combination thereof.
 66. Themethod of claim 65, wherein the biological sample comprises the nasalmucus.
 67. The method of claim 65, wherein the biological samplecomprises the saliva.
 68. The method of claim 65, wherein an ELISA assayis used in detecting binding between SHH and the anti-SHH antibody. 69.A method of diagnosing a taste or smell disorder in a subject, themethod comprising: a) obtaining a biological sample from a subject,wherein the biological sample comprises nasal mucus, saliva, or acombination thereof; b) detecting a level of sonic hedgehog (SHH) in thebiological sample by contacting the biological sample with an anti-SHHantibody and detecting binding between SHH and the anti-SHH antibody; c)diagnosing the subject with a taste or smell disorder when the level ofSHH in biological sample is lower than a threshold level.
 70. The methodof claim 69, wherein the biological sample comprises the nasal mucus.71. The method of claim 70, wherein the taste or smell disordercomprises hyposmia, dysosmia, anosmia, phantosmia, or a combinationthereof.
 72. The method of claim 69, wherein the biological samplecomprises the saliva.
 73. The method of claim 72, wherein the taste orsmell disorder comprises hypogeusia, dysgeusia, phantogeusia, ageusia,or a combination thereof.
 74. A method of diagnosing and treating ataste or smell disorder, the method comprising: a) obtaining abiological sample from a subject, wherein the biological samplecomprises nasal mucus, saliva, or a combination thereof; b) measuring alevel of sonic hedgehog (SHH) in the biological sample; c) diagnosingthe subject with a taste or smell disorder when the level of SHH in thebiological sample is lower than a threshold level; and d) administeringan effective amount of a PDE inhibitor, or a salt thereof, to thesubject.
 75. The method of claim 74, wherein the biological samplecomprises the nasal mucus.
 76. The method of claim 75, wherein the tasteor smell disorder comprises hyposmia, dysosmia, anosmia, phantosmia, ora combination thereof.
 77. The method of claim 74, wherein thebiological sample comprises the saliva.
 78. The method of claim 77,wherein the taste or smell disorder comprises hypogeusia, dysgeusia,phantogeusia, ageusia, or a combination thereof.
 79. The method of claim74, wherein the PDE inhibitor, or a salt thereof, is a non-selective PDEinhibitor, or a salt thereof.
 80. The method of claim 74, wherein thePDE inhibitor, or a salt thereof, is a selective PDE inhibitor, or asalt thereof.
 81. The method of claim 80, wherein the selective PDEinhibitor, or a salt thereof, is a phosphodiesterase-1 selectiveinhibitor, or a salt thereof; a phosphodiesterase-2 selective inhibitor,or a salt thereof; a phosphodiesterase-3 selective inhibitor, or a saltthereof; a phosphodiesterase-4 selective inhibitor, aphosphodiesterase-5 selective inhibitor, or a salt thereof, aphosphodiesterase-10 selective inhibitor, or a salt thereof; or anycombination thereof.
 82. The method of claim 74, wherein the PDEinhibitor, or a salt thereof, is roflumilast, or a salt thereof;cilostazol, or a salt thereof; or any combination thereof.
 83. Themethod of claim 74, wherein the PDE inhibitor, or a salt thereof, istheophylline, or a salt thereof.
 84. The method of claim 74, wherein thePDE inhibitor, or a salt thereof, is administered intranasally.